GW1--04838_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. n.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if apRticable)
. CLYDE SAWYERS&SON WELL& PUMP INC FRONT io DI&ME MR THICKNESS MA•IERIA1.
+1 It. 98 ft. 6.25 In. #21 PVC
Company Name W24-0053 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FRo N1 TO DIAME FE R THI(KNESS MATERIAL _
List all applicable well consnvctfon permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM. TO DIAMETER _SLOT SIZE THTCKNFSS MATER!AI
Agricultural DMunicipal/Public It. ft. in.
Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in.
industrial/Commercial ['Residential Water Supply(shared)
18.GROUT
Irrigation FRONT 'IT) NIAI'lRI 4,1. E NI PI.ACEM ENT METHOD&AAMOUN'I'
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
Monitoring DRecovery D. ft. Cap Top with Bentomite chips
• Injection Well: fr. rt.
Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD _
Aquifer Test DStormwater Drainage ft. ft.
0 Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer20.DRILLING LOG(attach additional sheets if necessary-)
Geothermal(Heating/Cooling Return) ['Other(explain wider#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
0 ft. 98 ft. OVER BURDEN
07-17-24
4.Date Well(s)Completed: Well 1D# 98 fIL 605 f• GRANITE
Sa.Well Location: ft. ft. ! -.
Jesus Bautiste/Clayton Homes ft. R. `•^L.. '. + 1,_L.
Facility/Owner Name Facility ID#(if applicable) ft ft. lJ
l C 1 G 2024
190 Moffitt Branch Rd., Old Fort ft. ft.
Physical Address,City,and Zip ft R. �'�
McDowell 065900543117 21.REMARKS .
County Parcel Identification No.(PIN) SELF CERTIFY
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 07-31-24
6.Is(are)the well(s)0x Permanent or 0Temporarc Sign,,_ cd ontractor Date
By signing th arm,I hereby certifj•that the wilts)was(were)constructed in accordance
7.1s this a repair to an existing well: ['Yes or 0No with 1SA NCAC 02C.1)100 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 well owner.
repair under el remarks section or on the back c f 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: ' • $UBMITTAI.INSTRUCTIONS
9.Total well depth below land surface: 605 (fit.) 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 2g/WY) construction to the following:
10.Static water level below top of casing: 50 (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 Iniection 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) 2 Method of test: RIG 24c.For Water Suo*ly&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: 28 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