GW1--01108_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Kolb Mitchel Sawyers wyers
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FROM TO DESCRIPTION
Well Contractor Name ft. ft.
I
4471-A
ft. ft.
NC Well Contractor Certification Number •'
�at5«Ol1TEticASllvG:(foi'<tnntd cisetf +eugibu: tNtizi(ie Itcastei��;-
CLYDE SAWYERS&SON WELL&PUMP INC FROni To IMAM E TER"fit ICKNr:SS MATERIAL _ _
+1 fL 111 ft' 6.25 'n #21 PVC
Company Name
W23/24-0092 ;61 INiYER'GASll4fiaORTuerl�G:`tcoliarinaGcla's'cd=t40p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i�SRER�i � � � s
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
MI Agricultural ®MunicipaUPublic ft. ft. in.
)111 iGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
jai industrial/CommercialResidential Water Supply(shared) g ROI)'P .` e
!Irrigation FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft' Bentomite' Pumped
NI Monitoring nRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
al Aquifer Recharge ®Groundwater Remediation
101,SA D/ ' 1?ELTAGK'(ifapvlfcala14,'` ,1 .:
$1 Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test 0 Stomiwater Drainage ft. ft.
j i Experimental Technology 0 Subsidence Control ft. ' ft.
!Geothermal(Closed Loop) 0 Tracer 20s 1ftlfI I13G '(Waiisatililldtiiahalwsheef¢if i'e"cessari} '
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
)I!Geothermal(Heating/CoolingReturn) ®Other(explain under#21Remarks) 0 tt. 111 fir• OVERBURDEN
4.Date Well(s)Completed:11-27-2023 Well ID# 111 ft' 305 ft' GRANITE
ft. ft.
5a.Well Location: 1-� '_...
.-.4 . y�"_'t l�p,r�-s.•-•.-
ft. ft. • 0 5".- E i' V' i `
BOYD ARROWOOD/CLAYTON HOMES 9w ,;"
Facility/Owner Name Facility 1D#(if applicable) ft. ft. f-E8 •r e�i. 202A
2522 MT HEBRON ROAD OLD FORT, NC 28762 ft. ft. LJ i
Physical Address,City,and Zip fL ft. iinCc n roi£ 'i I?f{ y �8��
r (N 70
MCDOWELL 064700180365 2HH REM RKS;A. � ` �%
County Parcel identification No.(PiN) Well was self certified
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
N W ! 11-28-2023
6.Is(are)the well(s)0X Permanent or DTemporary Signa e of el' ed ohhactor Date
By signing th brm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or [3No with 15,4 NCAC 02C.011)1)or 15A NCAC(I2C.0201)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 tothe well owner.
repair under#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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'
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 wells list all depths if different(example-3@,200'and 2 g./00') construction to the following:
10.Static water level below top of casing: 50 (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.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Injection 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: 30 completion of well construction to the county health department of the county
where constructed.
Form CiW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016