GW1-2023-00615_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: f
This form can be used for single or multiple wells `[(
1.Well Contractor Information:
GARRETT CLYDE BANKS FROM FROM��n�Q�s.«
TO DESCRIPTION
Well Contractor Name ft. ft. { i
4519-A ft. ft.
NC Well Contractor Certification Number 15..t)U3i RGiIY foriuld easedeiis OIE?l iNk:ila ileab`lc
FROM TO DIAME.TF.R 1 TWCKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 80 rt. 6 1/4 1 in #21 1 PVC
Company Name i1N.NEK C� IlYG UR T(7BING "eGfh�rnlniloSed-tQt}
055-2022-042.1 FROM TO UTAMF.rF.R' THICKNESS MATKRIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable ii-ell permits fl.e.County,Stat(,,,Variance,Injection,etc,) ft. ft. in.
3.Well Use(check well use): _ SE12Erk -
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it, ft. in.;
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in•
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT MF,THOD&AMOUNT
❑hri ation 0 et• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. tt.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
0.-1Jf#11-'1A G:= t]G.(aftaeti.adtliti"riaCstreetsidauecessa z:F
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock ri a grain size,etc.)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 80 ft OVER BURDEN
12-30-2022 80 ft- 205 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
So.Well Location:
Dustin Wortman
Facility/Owner Name Facility ID#(if applicable)
Old Cagle Rd. ft. ft.
Physical Address,City,and Zip
Henderson 959718.8532 This well was self certify
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) I
N W 12-30-2022
Sign tore of Certi Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this•farm,I herehv certify that the well(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 N'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knoun well construction information and explain tire nature of the
repair ender#21 r•emarlo•section or on the back of this Jbrm- 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 addition Fl page3_.i£nec%sary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS `=•-.
Jr"
i rc 'E
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this!form within 30 d'4A1lof&oFlejjpp,rof well
For multiple wells list all depths if different(example-3@200'and 2(a'1001 construction to the following: C ll Z
10.Static water level below top of casing: 30 (ft.)
Division of WaterResources,lnformationtPrbc�e±su3g tFpit �tl.;
If abler level is above casing.use"+" 1617 Mail Service C Inter,Raleigh,NC Y7699-1bI7G
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: IInladdition 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
(i.e.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CcIn'r,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RIG
24c.For Water Supply&InjectionlWells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. PILLS Amount: 20 well construction to the county heailt i department of the county where
constructed. I
Foray GW-1 North Carolina Department of Environment and Natural Resources—Division ur Water Relsources Revised August 2013