GW1--04491_Well Construction - GW1_20230713

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
i
Kolby Sawyers .Th.WATER ZONES . ;_
FROM TO DESCRIPTION
Well Contractor Name ft ft.
4471-A
ft. ft. '
NC Well Contractor Certification Number -'15.-OUTER CASING(forr multi=cased`wells)OR LiNER if applicable)( pp )
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 75 ft. 6.25 in. #21 PVC
Company Name
389969-2 '16.INNER CASING OR TUBING`(geotlermal closed loop)' ,:',
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: 17.SCREEN -•.-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) E3 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18 GROUT - .sr
Irrigation FROM TOE MATERIAL EMPLACEMENT METHOD Se AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite,' Pumped
Monitoring 0 Recovery ft. ft. Cap Top with Bentomile chips
injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remcdiation
'"19.SAND/GRAVEL-PACK(if applicable)" "'
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer "20.DRILLING LOG(attacicaddltionatslieets If necessary). M, ^-
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
0 ft. 75 ft. OVER BURDEN
4.Date Well(s)Completed:06/26/2023 Well ID# _ 75 ft. 605 ft. GRANITE
5a.Well Location: ft. ft. ,,
( , ;i !, "'I,
!' -rt '-.
Travis Fox/North Woods Lawn&Land LLC H. ft. •� �j(�
Facility/Owner Name Facility ID#(if applicable) ft. ft. JIJ! 1 ;. L023
Morlin Acres Drive, Marshall NC 28753 ft. ft.
int..'s^af^a) TPr^.r:'`tig !..lt-.Yi
Physical Address.City,and Zip ft. ft. MCA, :
Madison 9725-00-9308/9725-00-6
County Parcel Identification No.(PiN) this well was self certified
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w 06/28/2023
6.Is(are)the well(s)ElPermanent or Temporary Sigma c of Cc ed ontmctor Date
By signing dr form,I hereby cer•tyy that the wells)was(were)constructed in accordance
7.is this a repair to an existing well: ()Yes or DiNo wi//i 15A NCAC 02C.0100 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay use the back of this page to provide additional well site details or well
construction,only 1 GW-I 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: 605 (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@200'and 2 r@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 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) 1/2 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: 15 completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016