GW1--06069_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
1 1
Kolby Mitchel Sawyers 'MVATERIDrTsA :,_ ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.:
4471-A rL ft.
NC Well Contractor Certification Number 15 ti(Ftlitft AR)'1Yt,{fof iiiid cas�it�rr'el)sttiffkGlNRiti(itatrfc9fiie)��
CLYDE SAWYERS &SON WELL&PUMP INC FROM TO Il1.AME'I'ER THICKNESS M.ATERAAI.
+1 Company Name _ • 6.25 1O• #21 PVC
MCM-396W 1 # L k t` VIDNIG aililf iiiifctosca=kiop) '
IG,IIYiVRR�G�iYSCRC(IR;T
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG Counts',State.Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: MGRE» ? x
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
al Agricultural 0 Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
*ITndustrial/Commercial OResidential Water Supply(shared) LitEGRaUT:, :r,N:Ni ' `'.
I irrigation FROM TO MATERA.AI. EMPLACEMENT METHOD&ASIOUNT
Non-Water Supply Well: o ft. 20 ft' Bentonite1 Pumped
ill 1 Monitoring DRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
*)Aquifer Recharge 0Groundwater Remediation
IA Aquifer Storage and Recoveryt3 AND)G'RAVBSI'XGK(itii plit:al lORYW. , "i..:
11 q g 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
!Aquifer Test OStonnwater Drainage ft. ft.
•
Experimental Technology 0Subsidence Control ft. ft. i
*Geothermal(Closed Loop) IDTracer 20: RIIEINGr lOTat"'a"eliiddltiona tiee#stifYnecessaTh....
FROM TO DESCRIPTION(color.hardness,soilfrock type,grain size.etc.)
a Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks)
0 ff. 24 ft* OVER BURDEN
4.Date Wells)Completed:7-7-2023 Well TD# 24 fL 105 ft, GRANITE
5a.Well Location: ft ft. J L F.,b 11 f a.l;
rL ft.
' -.�Rid IL-.i 4 0.-_L.//
Randall Dawayne/Amanda Lanning
Facility/Owner Name Facility iD#(if applicable) ft. ft. 1 SEP
Q i, 1 9f17']
Long Branch Road Clyde, NC 28721 ft. ft. I J I LUiCJ
Physical Address,City,and Zip ft. ft. • llNaNvt r;lt �J0 b�}' u�''�
l r.Orr 3Cm
Haywood 8638-04-3961 '
County Parcel identification No.(PiN) this well was self certifiAd
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
N " 1 7-10-2023
6.is(are)the wells) Permanent or E3Temporaty Signa a of er ed onhudor Date
%
By signing th.form,I hereby certifj'that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 0Yes or 0No with 1.5.4 NCAC 112C.0100 or 15A NCAC(12C'.0200 Well Construction Standards.and that a
If this is a repair.frll out known well construction hlfonnation and explain the nature of the cop'of this record has been provided to the well owner.
repair under#21 remarks section or on the back r f this form.
23.Site diagram or additional well details:
S.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: 105 (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 l0(1') construction to the following: 1
20
1
10.Static water level below top of casing: (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) 50 Method of test: RIG 24c.For Water Supply&Inlection•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. I
Form CW-1 North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016