GW1-2022-07712_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.R`1TER"ZAl!iES .
GARRETT CLYDE BANKS
FROM TO DESCRiPTTOV
Well Contractor Name rt. ft.
4519-A
NC Well Contractor Certification Number 15.UUT>f1 GASING for d caseiTSvells.OR`L1NER.tf IlcaLiLe:`:
FROM TO INAMFTF.R THICKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 148 ft. 6 1/8 in #21 1 PVC
t6.:liyN£R;CA$I1VG-OR TliB1NG QpthermaE closed-too
Company Name
19100112498 FROM I'O DIAMETER1'HICKNMSS MATERIAL2.Well Construction Permit#: ft. ft. ! to
List all applicable mvil permits ti.e.Countt•,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): t7.S12E£ri
- "-- TO-�� DIAMETER' SLOT THICKNESS MATERIAL
Water Supply Well: FROM
ft. a. in..
❑Agricultural ❑Municipal/Public
ft. Ct. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
t&GROUT
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATFRIAL EMPLACEMENT METHOD&.AMOUNT
❑itt; ation 0 rt• 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge I]Groundwater Remediation 19:SA N➢1GRAYEL'PAGK:If a '"sable
FROM TO 1 ATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20%3.1R11;L1NG`LOt;;atraetiat3aitiiiiriLsheatsidiecessary �:.-... .:
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soilfrmk tv a gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 fr. 8 ft. OVER BURDEN
07-11-22 48 rt 105 fr GRANITE
4.Date Well(s)Completed: Well ID# R. ft.
5a.Well Location:
C M H INC
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
�y b.�, r
254 Moss Hill Dr ft. ft. .—a
Physical Address,City,and Zip21:REMARKS
Henderson 9681106492 Infic;tr�tac� ref)^t-»�;m_
County Parcel Identification No.(PIN) JiA V}%1i��1j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one ladlong is sufficient) "AkI
N W 07-15-2022
Signature ofCertr Well Contractor Date
6.is(are)the well(s): 17Permanent or ❑Temporary
By signing this form.!herehr eern(y that the well(s)wcu/were)constructed in accnrrlanee
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo ropy ofthis record has been provided to the well owner.
If this is a repair,fill out known.-ell construction iii rinatiun mud explain the suture of the
repair under#21 remark section or un the hack r fMis/i)rm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well"list all depths ifdilf rent(example-3(aj200'and 2(ar100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ij w»ter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: IiIn 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
t
13a.Yield(gpm) 50 Method of test: RIG
24c.For Water Supply St Injection'Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS ,Amount: 19 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013