GW1--03501_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES =�
Well Contractor Name FROMTO DESCRIPTION
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER(if ap,ikable)
CLYDE SAWYERS&SON WELL&PUMP INC FRosl To DItsil i :R THICKNESS MA ERLu.
+1 ft. 84 ft. 6.25 in- #21 PVC
Company Name
393629-2 16•INNER CASING OR TUBING(geothermal closed-coop) —.
2.Well Construction Permit#: FROM I() 111AM P:t r:R LID(I.NESS M5 rEw,u.
List all applicable well construction permits ti.e.UIC,County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
-
FROM •IU DI_\MF IFR SLOT WY_ l'IIIC KNFNC Nisi FRI aI
°Agricultural ®Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) I3 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
°Irrigation FROST 'to SI.5 tI'Ri SI. FMiP1,1f•FMEN r ME I HOD&AMOUNT
Non-Water Supply Well: r1 rt. Rs ft. Bentonite Pumped
Monitoring ®Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
°Aquifer Recharge ®Groundwater Remediation
Nl.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery °Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Slonnwater Drainage ft. ft.
(DHxperimental Technology OSubsidence Control ft. ft.
E3Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
0 ft• 70 ft• OVER BURDEN
5-24-2024 70 It 805 ft• GRANITE
4.Date Well(s)Completed: Well 1D# t1 .....
5a.Well Location: ft. ft. F !@ o,1 r
JACK KITCHING(WEL#4827) ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN 1 2 2014
7817 NC 213 HWY MARS HILL, NC 28754 fL ft. Ir4or.r.:.i ri P•r_.. ::,$LI-s,x
Physical Address,City,and Zip ft. ft. DWC t:
MADISON 9747-34-0307 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
Orwell field,one Iat/long is sufficient) 22.Certification:
N W 6-5-2024
6.Is(are)the well(s)0 Permanent or OTemporary Signs e offer ed nntractor Date
By.signing th Orin.1 hereby cei'f jr that the well(sl was(were,constructed in accordance
7.Is this a repair to an existing well: O Yes or x°No with 15.4;VCAC 02C.w/tol or ISA 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 veil owner.
repair under 1121 remarks section or on the hack 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-I 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: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-301200'and 20000') construction to the following:
10.Static water level below top of casing:200 , (ft.) Division of Water Resources,Information Processing Unit,
if water teve/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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 3 Method of test: RIG 24c.For Water Supply& lniection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 35 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016