GW1--01117_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers '14.WATEREZONES . .. ".,'. . � „.
Well Contractor Name FROM TO DESCRIPTION
4471-A ft. ft.
ft. ft.
NC Well Contractor Certification Number t
IS.OUTER-CASING(faVittilltgeaked-iuells)'OR LINER(if:ap"lreahle),,,-- , ,;.w„'
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 H. 63 ft. 6.25 in' 188 STEEL
Company Name
2023-24763-9-12890 16.INNER CASING OR TUBING(keutliermxi closed loop) -° .1 , -..
2.Well Construction Permit it: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits a.e.UIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN r"`.,
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
*Agricultural DMunicipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) EPResidential Water Supply(single) ft. ft. in.
illl Industrial/Commercial QIResidential Water Supply(shared) ,18 GROUT_ �•; .,, '
IJ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a R. 20 ft- Bentonite Pumped
AEI Monitoring EpRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft. I
Illi Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '' a-
*Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD r
*Aquifer Test DIStormwater Drainage ft. ft.
IN Experimental Technology 0ISubsidence Control ft. - ft. '
*1 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) .
111
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type gain size,etc.)
0 ft. 63 ft. OVER BURDEN
4.Date Well(s)Completed: 11-02-2023 Well ID# 63 ft- 186 ft. GRANITE
ft. ft.
5a.Well Location:
Jay&Deanna Alien ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
335 Dills Branch Rd rt. ft. .- T
Physical Address,City,and Zip ft. ft -A. --
li.�ti�,��
Sylva o sell �>,6 7643-80-9873 21.REMARI(S.."' w.,. '. '['-[° F iit,1--E 20t4 _a.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: vo,.+
CG
(if well field,one let/long is sufficient) 22.Certification: Din a
N " 11-02-2023
6.Is(are)the well(s) Permanent or Temporary Signs c of Ce cdZolitractor Date
By signing th form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: It Yes or EiNo - with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 185 (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@I00') construction to the following: 1
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) j
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
ROTARY above,also submit one copy of this form within 30 days of completion of well
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
13a.Yield(gpm) 20gpm 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: 15 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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