GW1--04836_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
KolbyMitchel Sawyers — —
� l4:WATER ZONES
FROM TO DESCRIPTION _
Well(;ontraclor Name
ft. ft.
4471-A
rt. ft.
NC Well Contractor Certification Number
1,.OUTER CASING(for multi-cased wells)OR LINER(if op *cable)
CLYDE SAWYERS&SON WELL&PUMP INC FRo>I To I)IAME I'CR THICKNESS MA'FE:RIAI. 1
+1 ft. 100 ft. 6.25 in. #21 I PVC Company Name ------•
W24-�056 16.INNER C.1SING OR Tt BING(gcorhermal closed-loop) --i
2.Well Construction Permit#: FROM To . DIAMETER THICKNESS MA'IERIAL __
List all applicable well construction permits(i.e.UIC.County,State. Variance.etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well:
ft. ft. in.
17.SCREEN
FROM CO DI t'incFFR <I-o'r St/F THICKNESS MA fERt-sL
Agricultural [3MunicipalPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) el Residential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation
Non-Water Supply Well:
FROM ro 'it- 'IRlu a�IFl,ett'Mr.n'I attlnon&AntoFNi
o ft 20 ft. Bentonite Pumped
Monitoring
Injection Well:
®Recovety ft. ft. Cap Top with Bentomite chips
{
fr. ft.
Aquifer Recharge ®Groundwater Remediation 1
19.SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery 0Salinity Barrier FRiot rtt �I'.FERIA!,tr, ran'I.0 4-�D:s r sD,i HOD
1
Aquifer Test ®Slonnwater Drainage it. D.
Experimental Technology ®Subsidence Control ft. fr.
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG(attach additional sheets if necessary):,
FROM TO
ft. 700 ft. DESCRIPTIONOVERBURDEN(coins.hardness,soifrork tppc.trim.in•.c•Ic.)
Geothermal(Heating/Cooling Return) LjOther(explain under#21 Remarks)
4.Date Wells)Completed:7-15-2024 Well M# 100 ft• 505 ft• GRANITE
ftSa.Well Location: , , 11L•-.�:
THE PITROLO COMPANY ft. ft.
ft. — ft. AUG 1 ' 2024
Facility/Owner Name Facility ID#(if applicable)
47 HONEYCOMB DRIVE OLD FORT NC 28762 ft. ft. Imam.74774,I,r 4-,,,
Physical Address,City,and Zip ft. rt. <<t,
MCDOWELL 066900200270 2t.REMARKS
County Parcel Identification No.(PIN) WFI L WAS SFLF C:FRTIFIFf 1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - — —1
(if well field,one lat/Iong is sufficient) 22.Certification:
N W 7-17-2024
6./stare)the well(s)0Permanent or OTemporary Sigma a offer ed onnacmr Date
By signing th orm,I hereby Err*that the well/#)ties(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or xONo with/5.4 NCAC 02C.VIOl)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 melt owner.
repair under#21 remarks section or on the hack of this limn.
23.Site diagram or additional well details:
R.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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
I/water level is above easing,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
13a.Yield(gpm) 50 Method of test: RIG' 24c.For Water Supply&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: 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