GW1-2023-00614_Well Construction - GW1_20230105

! I
WELL CONSTRUCTION RECORD `
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: {
GARRETT CLYDE BANKS FROM T TO - DESCRIPTION
Well Contractor Name ft. ft. f
4519-A ft. ft.
1rs:f3U1�R it El+tO.forT tarircasetl"stvelts.OIt1 NC Well Contractor Certification Number
"IN ifis ttcabtc"
h
FROM TO DIAMETFRI I TMCKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 it. 6 1/4 #21 PVC
Company Name 16:1NNER.,c tNixOlvw1fB13Y0- dthBrriia!,' SH1FIA .
055-2022-0474 FROM ITOI DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable%vil permits(i.e.County,State,Variance,Injection,etc,) ft. ft. j in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it. ft. in.
❑lndustrial/Commereial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AM NT OU
❑ anon 0 ft 20 ft Benton.ite. Pumped
Non-Water Supply Well: ft: ft.
❑Monitoring ❑Recovery
Injection Well:' ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation . -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. fr. !'
❑Experimental Technology ❑Subsidence Control
�q:�1fT2tC,L'tl!ICIOG attaelr,additiai.:hfsheeetaifnecessalw"` ---...� � .:: ''���=
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness so!Urmk type. ram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 56 OVER BURDEN
12-29-2022 56 rt• 185 ft• { GRANITE
4.Date Well(s)Completed: =Wefl 1D4 ft. ft.
5a.Well Location: ft. ft.
CMH Homes
Facility/Owner Name Facility ID#(if applicable)
ft, ft,
60 Woodrow Way, Lot 1 ft. ft.
Physical Address,City,and Zip fit.-:RE1►7ARKS.: ..
Henderson 9690861919 This well Is self sertify
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: n tare o
22.Certification:
(if well field,one lat/long is sufficient)
N W
12-30-2022
Sigind.UWtel,6C...ctor i Dale
6.Is(are)the well(s): gPermanent or ❑Temporary By signing this firm,1 herehv certify'thii the well(s),vas(were)constructed in accordance
pith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Consn•uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out kno»v/well construction information and explain the nature of the
repair under#21 remarks•s'ectlon or on the back of this•form. 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: construction details. You may also attach additional}1ges^ifinecessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can t
submit one form. SUBMITTAL INSTUCTIONS j �" '?` r
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this'form within 30 da,�A®p congictiojl�f well
For multiple wells list all depths ifdif rent(example-3@200'and 2@100) construction to the following: CY+ 3
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,lnformationTA2.?mW.t tit,
If unrer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 2 t67I +•16L'6 j( nil
11.Borehole diameter: 6'25 (in.) 24b.For Infection 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
13a.Yield(gpm)
50 Method of test: RIG 24c.For Water Supply st InjectionlWells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 20 well construction to the county health)department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013