GW1--07553_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers a4MATtRzONE ::, , �;. , OMax_ ,.r..'
FROM TO DESCRIPTION
Well Contractor Name • ft ft.
4471-A
ft. ft.
NC Well Contractor Certification Number .0.'1)llTEICCASfNVG(for uuttt caseei<wetis)t)R LINEk(if.=sp litibtc)....0i
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER .' THICKNESS MATERIAL
+1 it 135 ft' 6.25 I rw #21 PVC
Company Name
OSS-2023-1077 161N(?11;R..SINC.URT[GB[NC.{Q thet'niuFclpsett 1pltp):=t...,,.,.: ..*.,: ,...<
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) . ft. ft. ; in•
3.Well Use(check well use): ft ft, in.
Water Supply Well: 371..S:cBEEl��.-::z �, x'` ,�. _„ . --:.,r4 ` .a- �...;- . . .�:
PP FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural 0Municipal/Public ft. ft. in.1
Geothermal(Heating/Cooling Supply) 12 Residential Water-Supply(single) ft. ft. in.
'industrial/Commercial DResidential Water Supply(shared) ACGROlitSiMniiiMO•
MCM:WigiiMMVAMM.MiZMOM-IIM
'irrigation - FROM TO al ATERIA I. FM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• Bentonite Pumped
Il I Monitoring nRecovery • ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft. •
)<i Aquifer Recharge 0 Groundwater Remediation
' ,�-txt c t r€
.29,Si�PIINGRA',C?ELPA -Gf�tfivlt�btny .-----:_ �...�..Ns�...f�sF---�.:-- .....-«-�
j !Aquifer Storage and Recovery 0Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
a Aquifer Test 0Stonnwater Drainage ft. ft. ,
L Experimental Technology ®Subsidence Control ft. ft.
'Geothermal(Closed Loop) 0Tracer 2111Htll;L1NOLO( (attache abdlf1tin61: eetsafjieressat3): Mz Mom;;,• ;-
FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,eta)
�Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks)
0 tt• 135 ft.
OVER BURDEN
4.Date Well(s)Completed:10-11-2023 Well ID# 135 ft. 225 ft* GRANITE j"" T r ,
5a.Well Location: ft. ft. Y' v. :) ai .�
CMH HOMES INC ft. ft. N®V- 9 " 2Q23
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,
ft. ft. It)ic;7r,:-..'^;I ,a!- raj Ur t
212 Woodrow Way, Lot 13 ,,:
Physical Address,City,and Zip ft. ft.
HENDERSON 9690870442 zl:ItEIVIAR7 I s= M > . M.--x_,----=zsW <... M
,.t
County Parcel Identification No.(PiN) 1 T his well was sells Certlfiid
•
I,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
is
N V1
10-12-2023
kri÷'o ed onhaclor Date
6.Is(are)the well(s) Permanent or Temporary
By signing Ili.Jinn,I hereby rerti/i'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or % No with 15A NCAC 02C.0100 or lSA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under till remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For CeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS j,
1
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of-well
For multiple wells list all depths if different(example-3@200'and 2(a;I00) construction to the following: II
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
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,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) 10 Method of test: RIG 24c.For Water Supply&Iniection(Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to tie county health department of the county
where constructed.
Form CrW-i 'North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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