GW1--03548_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS
FROM TO DESCRH'TTON
Well Contractor Name ft. ft. I I
4519-A ft. ft.
NC Well Contractor Certification Number _t5;a7tTERGAStNG.fo'rtnaltleasedlwetls'.OR:L1NEtZifs hcable:
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 177 ft. 6 1/8 ' #21 PVC
Company Name 16•1NNER CA$iNG OR:TU111N .eutIni Ai'closed I ::
OSS-2023-0234 FROM DIAMETER THICKNFSS MATERIAL
2.Well Construction Permit#: ft ft. to
List all applicable well pennits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.,SCREEN.-.::a......
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS 11fA.EMAIL
ft.
❑Agricultural ❑MunicipaUPublic ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. it. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
PP y(� FROM TO MATERIAL EMPLACEMENT METHOD&.4MOUNT
❑hTi ation 0 et. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑AgwferRecharge ❑GroundwaterRemediation F9RS�NDAYEL IGRPAGK'!F4 Wble TO
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT aIETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2U iif121GL1NG:—t a1fa"ch addi onnlsheefs>ifnccesss
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/rock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 77 ft. OVER BURDEN
5-10-2023 77 f° 505 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft ft.
Jane Rose � ���"'��'�-� a-' ��•
ft. ft.
Facility/Owner Name Facility ID#(if applicable) MAT'
ft. ft. 9 2023
166 Allen Springs Rd
f<.4'•1
Physical Address,City,and Zip 2f:Rf MARKS'< .: ._..
Henderson 9529153455 This well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one fat/long is sufficient)
N 05/10/2023
Signature ofCettt W�eJIC.fflnctor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I herehy certify that the well(s)was(were)constructed in accordance
with 1 SA 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 owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair tinder#21 remarks section 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 pages if necessary.
For multiple injection or non-water supply wells ONLY with the sumo construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple tvellr list all d<:pths if dtlj rent(erample-3(aj200'and 2(a,100� construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
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: constmction to the following:
(i.e.auger,rotary,cable,direct push,etc.) DiAsion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCelnter,Raleigh,NC 27699-1636
I
2
13a.Yield(gpm) Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this florin within 30 days of completion of
13b.Disinfection type: PILLS Amount• 20 well construction to the county health department of the county where
constructed.
Forat OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013