GW1--04833_Well Construction - GW1_20240814

Print Form •1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Well(:ontrac tor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER(If ap Ikabte)
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DIAMETER 'rn1CKNISS MAIERIAI,
+1 rt. 120 ft. 6.25 in. #21 PVC
Company Name
W23-0250 Ill.INNER CASING OR TURING(geothernsalclosed-loop)
2.Well Construction Permit#: FROM 1.0 OLUO:IER Till(l.s.uSS NIkIFACIAL
List all applicable well construction permits(i.e.WC,('nuns'.State. Variance,en.) ft. ft. in.
3.Well Use(cheek well use): It. rt. in.
I ater Supply Well: _17.SCREEN
PP FROM 10 ill\METER SLOT SIZE rtttcK5rss \t4TFRLU.
Agricultural ®Municipal/Public ft. N. in.
Geothermal(Heating/Cooling Supply) 13 Residential Water Supply(single) ft. ft. in•
i udustrial/Commercial
i Irrigation
Non-Water Supply Well:
Residential Water Supply(shared) 18.GROUT
h'ROM TO NI 1-I'F.RI\I. F\IPLA('EI\l h'NT MI'I11gD&>\IOl�T
0 ft. 20 ft. Bentonite Pumped
Monitoring
Injection Well:
®Recovery ft. it. Cap Top with Bentomite chips
ft. ft.Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK if a,,_icsiblg) '' '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft. ft.
pExperimental Technology ©Subsidence Control ft. ft.
Y-'I Isothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary) : "%r
FROM '1'O DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) E3 Other(explain under#21 Remarks) 0 ft. t20 tt. OVER BURDEN
4.Date Well(s)Completed:7-15-2024 Well ID# 120 ft. 185 ft• GRANITE
a j5a.Well Location: ft. ft. 1' a t•r: -' 1;-'
JASON GROSS/CLAYTON HOMES ft. ft.
Facility/Owner Name Facility ID#(if applicable)
rt. ft. AUG 2 2024
348 RANDALL ROAD MARION, NC I. ft. irrf;rr,4.tt 1 -rr ;t
Physical Address,City,and Zip ft. ft. I�rrf7;; ry
MCDOWELL 068900429496 �21.REMARKS
County Parcel Identification No.(PIN) vyFI I WAS_SEI F CFRIIFIFD _.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 7-18-2024
6.Is(are)the wells)JX. Permanent or ®Temporary Signs c of Cc ed ntranor Date
B1'signing th OM.1 hereby certiJi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or QNo with/5A;VCAC 02C.0100 or 1 SA 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 sell owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/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 OW-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 (fr•) 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 20-C109') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Wafer 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) 50 Method of test: RIG 24c.For Water Supply& lnjection 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 Water Resources Revised 2-22-2016