GW1--06097_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
GARRETT COLLIN BANKS I4:%r'ATERZOINE -,-AAT.5 0 ,.xINIR i, ;:r.. ,. t ,. 1 ,=.:;
FROM TO DESCRIPI'tON
Well Contractor Name ft. ft.
4519-A ft. ft. i '
NC Well Contractor Certification Number L5„bUTER:C'ASSING-(lbr'multi cWil fGe1ls)ORLiNER.(if up",pileable) . : `1.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f• 35 ft- 6 1/4 a in. #21 PVC
Company Name ri16 I19NER C iSING OR.TUIl1NG(gMtlte iiial:closed loop) r:. =-.4'!. , ;,',s
055-2022-0675 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ' in.
List all applicable well permits'Le.County,State..Variance.Injection,etc.) ft. IL in.
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3.Well Use(check well use): ;47;-SCREEN -.`i-, ,.j.r ., . iM,
Water Supply Well: FROM TO DIAJIETER i SLOT SIZE THICKNESS MATERIAL.
ft. ft. in. i
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
B
❑Industrial/Commercial ❑Residential Water Supply(shared) 48 GLt-OUT ,.„ ' ,.. ._ _ -' ,' s+•,>r
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
. ❑Aquifer Recharge CI Groundwater Remedialion ;19•.SAND/GRAVEL, ACK`t f tppfichlide): ''''','-':.''''A'.,..
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control •
''20:1)RILLIh(.LOG(attaeti addllionitit`sheets if riecessarvM x.. ,,_..''
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 35 ft. OVER BURDEN .
07/10/2023 35 ft• 605 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. p ' P'f c-,
' ''"' kl t LI
5a.Well Location: ft. ft.
Robert C.Moore jr&James White I ft. H. S E P 2 1
_ 21)Z3
Facility/Owner Name Facility 1Db(if applicable) ft. ft.
73 East View Drive, Flat Rock, 28731 Infnalikr4iP.in Qr`• t it
ft. ft. DVIOA,Y0
Physical Address,City,and Zip i21 RE MAR g'" . ,, "' ss.i 4 I<r_. .y, ,.::,„,e
Henderson 9586353399 Well was self certified
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `� 07/20/2023
Signature of Cent Well Contractor Date
6.Is(are)the well(s): CIPermanent or ❑Temporary
By signing this firm,!hereby certi/i•!hn)the well(s)was(here)constructed in accordance
with/5,4 NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
7.Is this a repair to an existing well: Dies or 1E1No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder 1121 remarks section or on the back of this form. 23.Site diagram or additional well'1details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the.saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
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30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) ,
If water level is above casing,use-4-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For injection Wells ONLY: iln addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f
) 1 RIG 24c.For Water Supply&Injection Wells:
(gpm)
Yield Method o test:
Also submit one copy of this for within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county he lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R(sources Revised August 2013
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