GW1--04822_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(far multi-cased wells)OR LINER(if applicable)
CLYDE SAWYERS& SON WELL & PUMP INC FROM 'to DIAMEI'H:R THICKNESS M.&IF:RIAI
+1 rt. 145 ft. 6.25 in- #21 PVC
Company Namc
EH 24799 16.INNER CASING ORTURING(geothermal closed-loop)
2.Well Construction Permit#: FROM To NAME[ER rlucANPSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance et) ) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM 10 1)1\'t F:I FR Cl-Ill'Mil' 1 rtncK\ra \I NII-RIM
OAgricultural ®Municipal/Public ft. It. in.
Geothermal(Heating/Cooling Supply) E i Residential Water Supply(single) ft. fr. in
Oindustrial/Commercial OResidential Water Supply(shared) 18.GROUT
rIrrigation FROM Tu \I>TFRI11 FiIPIACF\l FN.I 'IFr DOD&n'IOIyr
Non-Water Supply Well: o ft. zo tt. Bentonite Pumped
Monitoring ®Recovery It. ft. Cap Top with Bentomde chips
Injection Well:
ft. tr.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
)Aq Ili fer Storage and Recovery OSalinity Barrier mom To MATERIAL. EMPI.ACEME\T NW I'MOD
Aquifer Test OStomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control fr. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock hype,grain size,etc.)
Geothermal(Heating/Cooling Return) pother(explain under#21 Remarks) 0 ft. 145 fry OVER BURDEN
4,Date Well(s)Completed:7-8-2024 Well iD# 145 rt• 185 fr GRANITE
fL ft.
5a.Well Location: `" a„,„ O�.• _
JAMES HIRST ft. ft- 1."‘..�.., -;7 I 1:
Facility/Owner Name Facility lD#(if applicable) rt. rt. AUG 1 4 2024
TURNING LEAF LANE MILLS SPRING, NC ft. ft.
Physical Address,City,and Zip
ft. ft. -V.,: - 70.- 3,n,� ,
POLK 21.REMARKSD'i`.:....1st
County Parcel Identification No.(PIN) SFI F CFRTIFY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -I
(if well field,one lat/long is sufficient) 22.Certification:
N W _ 7-09-2024
6.Is(are)the well(s)0 Permanent or OTemporary Sig a of le ed ontractor Date
By signing ill Orin,I hereby certify that the neB(s1 mu(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or )No with 15.4,VCAC 02C.0/00 or 15A 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 lel remarks section or on the back t f this farm.
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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/ferent(example-3@21/0'and 2(a)100) construction to the following:
10.Static water level below top of casing: 35 (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 Infection 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
13a.Yield(gpm) 9 Method of test: RIG 24c.For Water Sunplv&Injection 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: 20 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 Wales Resources Revised 2-22-2016