GW1-2022-07715_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
GARRETT CLYDE BANKS FROM T O D . ....:
f T DESCRIPTION
Well Contractor Name ft. ft.
4519-A
15.:Ou 1 F CdSiN u.foraiuld ca" h O LflVt lt'fa Icire` °.0
NC Well Contractor Certification Number FROM TO DIAMETER I THICKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 40 ft 6 1/8 '" #21 PVC
Company Name 16 aNNEt2 C tN_D.l)A f tJ6)Nfx:"4Gth erRititiCIPSC+I 109" .
22100111189 FROM 1O DIAMETER '1.11ICKNFSS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Coum4%State,Yariance,Injection,etc.) ft. ft. in.
3.Well Use check well use):
Water Supply Well: FROM To DIAMETER 1 1 SLOT SIZE THICKNESS I afATERiAL
ft. ft.❑Agricultural ❑Municipal/Public i"•
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) Ct. tL in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) �-
FROItI TO MATERIAL FMPLACRMRNT MF.TAOD&A)fOtJVT
❑b,i ation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aqutfer Recharge ❑Groundwater Remediation 1➢:;S/SNIIJG1itlVE&TACK=rta " e>tbl�<....:.::. ...x.a......�x�.
FROM TO MATERIAL EDIPLACEME.NT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2tl-#fRittdh��(�O-sitfRe4satlt3 tau"� s'iteefsifnecessa :<-;.. x. __- -�'�:��� 3_�;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hsrdnes soivrmk ro e gnin size,etc.
[]Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 0 fr OVER BURDEN
07-14-22 40 ft 305 n GRANITE
4.Date Well(s)Completed: Well ID# ft ft
59.Well Location: ft. ft.
CM H INC ft. ft. _. .-. t
.ia.. •„D
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
68 Two Wheel Dr., Lot 5 ft. - ' 9 2@22
Physical Address,City,and Zip
Henderson 9599788056 21�1tEIVfARIfS r�t�ay DWQi ' ...
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)
08-12-2022 N W
Sipatt3e_ofCcrt—jft19 Well Contractor Date
6.is(are)the well(S): [aPermanent or ❑Temporary By signing this firrm.1 herehv certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standaidc and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair.fill out knoun well construction information and explain the nature of the
repair under 921 remarks section or on the back ofihic form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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 sume construction,you Can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'different(example-3(q�200'and 2(q'100') construction to the following:
10.Static water level below top of casing. 30 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: Ira addition to sending the form to the address in
ROTARY 24aabove, 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
13a.Yield(gpm) M i
ethodoftest:
5 RIG 24c.For Water Supply&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.
Fora GW-1 North Carolina Department of Environment and Natural Resources-Division of Water resources Revised August 2013
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