GW1--06074_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r Kolby Sawyers
\'ellConttactorName FROM TO _ DESCRIPTION
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number ��- a� -
15:6DIFt;Ree* fl t farimtitti ased�t eOlbitflAN 006 two—
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER I 'THICKNESS MATERIAl,
+1 ft. 45 ft. 6.25 ( 1O #21 PVC
Company Name a1 x x
DGS-039W diNNER.CA I Cart�r.,LtalNQWW U»at=eiasailati) '
2.Well Construction Permit#: FROSt 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. i in.
Water Supply Well: I; SCREENfe`' ` '," ' ,
pP FROM TO DIAMETER. SLOT SIZE + THICKNESS MATERIAL
•I Agricultural 0Municipal/Public ft. ft. in•'
MI Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in. .
'industrial/Commercial DResidential Water Supply(shared) a=" ,, -_"
IllIlrri ation FROM TO MATERIAL. FM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Bentonite i, Pumped
I Monitoring Recovery ft. ft. I Cap Top with Bentomite chips
Injection Well:
ft. ft. I
'Aquifer Recharge ®Groundwater Remediation
9. );:ININGRAVELVACKttifAilii6617, "
III Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3 Stonnwater Drainage ft. ft.
'Experimental Technology [3 Subsidence Control ft. ft.
'Geothermal(Closed Loop) ®Tracer 2O.l)TtILL NC I Ut;{atia l ad'diliunarittle"ts if<necss'sars) ,,.
FROM TO DESCRIPTION(color.hardness.soil/rock type.grain size,eta)
t Geothermal(Heating/Cooling Return) [3Other(explain under#21 Remarks)
0 ft. 45 ft• OVER BURDEN
4.Date Well(s)Completed:7-6-2023 Well ID# 45 ft. 165 ft' GRANITE
5a.Well Location: ft. ft. __,i r... ,I, f
Christian Rathbone ft. ft. aZ r.....`..r ..i_ 'V Z L
Facility/Owner Name Facility ID#(if applicable) ft. ft. SEP 1 2023
49 Annielee Lane Clyde, NC 28721 ft. ft. J
P c'..
Physical Address,City,and Zip ft. ft. 1 tfl[gi+ +FetShl * s e€Ui
Haywood 8721-0-2-7117 z'I RE UCSI. ' I , ; ,j"�•� '� �,4
County Parcel identification No.(PiN)
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 7-6-2023
6.Is(are)the well(s) Permanent or OTemporary Signs e of et ed onlraclor Date
x
By signing th ornr,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or x No with i5A NCAC 02C.0100 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 cop of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form. I
23.Site diagram or additional well'details:
8.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: 165 (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@l00') construction to the following: i'
10.Static water level below top of casing: 30 (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) 20 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016