GW1-2023-01983_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells 1
1.Well Contractor Information: 1
GARRETT COLLIN BANKS FROM TER>zol r.....:..:<•....:,.:.,.:.
FROM TO DESC'RiPTTON
Well Contractor Name
4519-A ft. ft. 6
NC Well Contractor Certification Number a5 0U CAR'CASING'toririotit=caseit:iivells'.OR"t tNER-if<s"'ticalik"-"z`:>
FROM TO DIAMETER, TAiCKNFSS pfATF.RiAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 72 ft 6 1/4 i #21 PVC
Company Name
T6::INNER"CASING ORI11B1NCY`"euttierriin['ctosed=l0tt r'? 3>': >:? ' `:;
OSS-2022-0514 FROM TO DIAMETER 'I'HICKNFSS MATERIAL
2.Well Construction Permit#: R. in.
List all applicable wr(l penrri[s(.e.Counn•,State,Parlance,Injection,etc.)
ft. ft. in.
3.Well Use check well use): ♦rf
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) 'IResidential Water Supply(sin(single) it. tt. in.
3&.'GROUT::%:';->::>-=:=--=3 -:='3:.:z;:'«4; ::;..:;<i<;>;<:` :z-' :":=>:-;::a
❑lndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rc. Ic. Cap Top with Bentonite Chips
[]Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation �49::SAND/GRAYEL'PAtK=iCa""
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft IL
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control ........_._._.........
A0 EDR1CtAN0,-L0G airaeli:additid t3tieets id iiecessarv"3i-e>: ,:<.:a:%<="s:-> s;:_:;<:
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soilIrmic type.grain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 r° 72 fr OVER BURDEN
4.Date Well(s)Completed: 02-17-2023We11ID# 72 ft' 305 fr GRANITE
ft. ft.
5a.Well Location:
Richard Kaltenbach
ft, ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. Lb 2, '(
luzi
106 May Dr ft. ft.
Physical Address,City,and Zip
Henderson 9650600331 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 lat/long is sufficient) n AA N W 02/17/2023
Signature of Ceit1 Well Contractor Dale
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this form.I herehv rert(jy that tire well(s)was(were)constructed in acrordanee
ivith 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Consb•uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E']No copy ofthis record has been prorided to the well owner.
1f this is a repair,fill out known well construction injurmatiun and explain the nature of the
repair under#21 remarks section or on the back ofthis fe,rm. 23.Site diagram or additional well details:
You may use the back of this page to pro%ide additional well site details or well
S.Number of wells constructed: construction details. You may also'attach additional pages ifnecessary.
For multiple h jeetion or non-water supply wells ONLY with the.came 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 wrllr list all depths i lijeren (eaple-3( 2and 2(u10f m4 0� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.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
13a.Yield(gpm) 3 Method of test: 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 25 well construction to the county health department of the county where
constructed. 1
Forin GW-1 North Carolina Department of Environment and Natural Resources-Division of water Resources Revised August 2013