GW1--04485_Well Construction - GW1_20230713

1
Print Form 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Sawyers .14.WATER ZONEs - . > -.: ..
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15:`OUTER CASING(foi.multi=cased,utells),ORLINER(if an licable)'
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft• 143 ft• 6.25 in. #21 PVC
Company Name
373667-3 '16::INNER CASING OR'TIJB[NG(geothermal closed loop).;i•'i ,. ,...
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared •)
18aGRbUT �, : ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite Pumped
Monitoring 0Recovery R. ft.
Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmediation
.'19.SAND/GRAVEL:PACK(if applicable) :'- '' =s
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,':20.01,iILL1NG LOG(attar)i additional sheets if necessary) ' : ' -:_
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soIl/m eLt type,grain size,etc.)
0 ft• 143 ft• OVER BURDEN
4.Date Well(s)Completed:06/22/25023 Well ID# 143 ft. 545 ft• GRANITE
5a.Well Location: ft. ft. A� T
Bernice T. Metcalf ft. ft. '� - r -`,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Heritage Lane, Mars Hill 28754 ft. ft. JUI i .; 2023
Physical Address,City,and Zip ft. ft. Iflfi- 'T ;C.i1;fir•^,r•5,1,727g t
Madison 9757-40-1010 :21.REMARKS. '',.., ,F-.... i`,�. - ,- ''>-..=.32 z3 :.
County Parcel identification No.(PIN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 06/26/2023
6.Is(are)the well(s)OPermanent or OTemporary Sigma c of Cc ed ontractor Date
By signing lh m,i hereby co-fiji•that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: Dyes or IZINo wills 15.4 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction is formation and explain the nature of the copy of this record has been provided to the well owner.
repair tender#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I 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: 545 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 200'and 2@l00) construction to the following: ,
10.Static water level below to of casin 35
p g: (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 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) 3 Method of test: RIG 24c.For Water Supply&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: 20 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources : Revised 2-22-2016