GW1-2023-01984_Well Construction - GW1_20230227

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
7Ahi GARRETT CLYDE BANKS FROM 5_TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. fr. C
NC Well Contractor Certification Number t5 OUCER'CASti�EtY:'foriiiult calied(wells
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft.
6 1/4 i #21 1 PVC
Company Name %tlb:liVNHR'CASINCr'QR.TUBING' fliet�iiaEttosetFlp4 ':;:=:<'s:z.':<: j:;?x: :`%s>':>;:>_:
OSS-2022-0540 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. in.
List all applicable aell permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): :x:::<----=- _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. fr. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. tt. in.
<'=.18(
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
y '❑Aquifer Recharge ❑Groundwater Remediation 1 .............................:...........:......
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERMI, I EMPLACEMENT METHODtt. tt.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
::::ZO•I1RT1 IiING:T i5G<a[t ieli"idditioiiht lieetr'ificcess"a"":=><:=`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/o k type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft• OVER BURDEN
02-09-2023 60 ft- 405 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft, ft. t.^ ' � 1° 4t-. .r
Gonzalo Hernandez ft. ft. FEB 2 7 2023
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
174 Stepp Mill Rd ft. ft.
Physical Address City,and Zi
YS Y, P - - '-'y=:•�Y-i<;;rs::>-;:-s::=ti:=:�::�:Ssi:=:-=::=;;six:r<_'>:z:;:=::r:�::-r-:�:;:�>::
:i21-REiV1ARK$;�f:'.i;�i? = ::::=:=#:z:::.�,
Henderson 9599881824 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 `i 02/10/2023
Sign taJL_AJre of Cedt Well Contractor Date
6.Is(are)the well(s): 2Per manent or ❑Temporary By signing this firm.1 herehv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 nr ISA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair,fill out knuim well construction inlormafion and explain the nature of the
repair under 921 remark-section or on the back oflhis 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 pages ifnecessary.
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:405 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For inaltiple wells list all depths ifdiljerent(example-3@200'anti 2(ar100) construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If utter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: 1 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
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed. f
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Foust CW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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