GW1-2022-07718_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple weals
1.Well Contractor Information:
GARRETT CLYDE BANKS 4��1 AiER 1!T S .... .•_
FR0 TO DESCRIPTTOTTO
N
Well Contractor Name
4519-A
NC Well Contractor Certification Number 15..DD3 ill -fora ulCl Bated e[fa.UW-LINEtt.if`s` Iti ab[e
FROM TO DIAMFTF.R TITICKNFSS 111ATF.RT 4I
CLYDE SAWYERS & SON WELL & PUMP INC +1 fi- 93 it• 61/8 l in #21 PVC
Company Name #iatrmalt►eselktuo .-� ----'----- :td,�1V1±1�t�CA$(lY{�bR. 4IN0 ta:
21120119353 ERONI 10 DIAMp IpR THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,State,Yar•iance,Injection,etc.)
ft. ft, in.
3.Well Use(check well use): t
Water Supply Well: FROM TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
t[. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) EIResidential Water SuPPIY(single) tt ft
in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑Tni ation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
ND�DL ': � e. �
❑Aquifer Recharge ❑Groundwater Rcmediation PRun MATE RIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soil/o k ri e rain size,etc.)
❑Geothermal Heatin Coolin Return ❑Other(explain under#21 Remarks 0 ft• 93 ft. OVER BURDEN
05-23-22 96 ft• 605 ft. GRANITE
4.Date Well(s)Completed: Well ID# fit
. ft.
s l
5a.Well Location: ft. ft. � 6_—"s V
Kimzey-Mills LLC ft. ft. 2
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Shep Dr., Lot 1 klfc:,rt,,3,c 1 Pmc:s:r1r,1 :t
Physical Address,City,and Zip 79r a
Henderson 9631064889
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 W n AA 08-05-2022
Signature of Cettt Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary
By sibming thisfinm.1 herehv certify that the wells)suns(were)constructed in accordance
with 15A 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 E]No copy of this record has been provided to the well oxwer.
If this is a repair•fill out knuitn well construction informatiun and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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: 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• 605 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdilferent(example-3(ti200'and 2(4.100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+^ 1617 Mail Service Cel ter,Raleigh,NC 27699-1617
II.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In 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
24c.For Water Supply&Injection!Wells:
13a.Yield(gpm) 1 Method of test: RIG 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. !f
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013