GW1--03549_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:
;14„R�A'1'EIt�7A1�lES.
GARRETT COLLIN BANKS FROM TO DESCRIPTION
Well Contractor Name ft. ft. I �
4519-A ft.
NC Well Contractor Certification Number 19f311TEBCA5tiY0 fot'TtutH casttl'weiis ORU1VEit-ifia"fi'cahie`:
FROM TO DiAMFTF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 62 ft. 6 1/s : i" 1 #21 PVC
Company Name a6„INNE1k CASING 01-1 UBINCY. 4pthet�jitl;closed luo
FROM 10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: OSS-2022-0426 26 ft ft. in.
List all applicable w el/permits(i.e.County,State,Variance,Iniection,etc.) ft. ft. in.
3.Well Use(check well use): u: ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. f[. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. tn•
❑Industrial/Commereial ❑Residential Water Supply(shared) 7If. RO[I F.-.. _:._ �- �._ .__:.::
FROM TO MATERIAL EMPLACEMENT METRO[&AMOUNT
111rri ation 0 ft' 20 it. Bentonite Pumped
Non-Water Supply Well:
rc. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.'SAND/GRA T!EI PACK if a `Ucable :..
FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Battier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2U b JLLING-LOG<attaeh additiarial heefs:ifnecessa'ry
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitfrocktypa grain size,etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 Cr' 62 fr' OVER BURDEN
5-10-2023 62 fr• 145 tr• GRRNITE_
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Remigia Espinosa ft. ft. 023
Facility/Owner Name Facility ID#(ifapplicable)
76 Sam's Dr ft. ft.
Physical Address,City,and Zip
Henderson 9519726438 This w4 was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 5-10-2023
Sign tore of Cestt Well Contractor Date
6.is(are)the well(s): RIPermanent or []Temporary By signing this form,I hereby cer4fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C..0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis 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 under#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: 1 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di ffi rent(arample-3(01200'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: 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
m 13a.Yield
(gP ) Method 20 of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
PILLS
13b.Disinfection type: Atnount- 20 well construction to the county heal Ith department of the county where
constructed.
Fors»GW-1 'North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013