GW1--06166_Well Construction - GW1_20230922

I.
Prinf Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: `
1.Well Contractor Information:
Kolby Sawyers 444.'WATERZoNEs .... ava . .
Well Contractor Name FROM TO DESCRIPTION
4471-A D. ft. iI
ft. ft.
NC Well Contractor Certification Number
A5,Olt ER,CASINOlfor'mutti eused*etas)"OR 11NRR 1164 Ilcable)'!'o: .'
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 It 40 ft' 6.25 in. #21 PVC
Company Name
W21-0648 J6:INNERT:ASLNG;OR lURING_(geatherrnat?closed toopy:it, , ,.,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17 SCREE11U..,�_ 1. ', "--x .� • _.u.
FROM TO DIAMETER r_SLOT SIZE THICKNESS ,MATERIAL
RIALv
I Agricultural DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. R. in:
Industrial/Commercial D.Residential Water Supply(shared) :YS:;<=ROUT
• 'I Irrigation FROM TO yMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft, 20 ft' Bentonite Pumped
MI Monitoring 0Recovery ft. ft.
injection Well: Cap Top with Bentomite chips
ft. ft.
*Aquifer Recharge 0Groundwater Rcmediation
im1.9 SAJS"D/GRAVEl PACK(ifapjSlieablejs_ .k:e
*Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft. r
Al Experimental Technology Ej Subsidence Control It. ft.
ill Geothermal(Closed Loop) • OTracer .,=20..DRILLING,LOG(attach addltionittslieetsifuecessarv) ,i; ,
itFROM TO DESCRIPTION(color,hardness,soit'rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) EtOther(explain under#21 Remarks)
0 ft• 40 ft• OVER BURDEN
4.Date Well(s)Completed:07/17/2023 Well ID# 40 ft• 265 ft'. GRANITE
5a.Well Location: It. ft. li 6f%r-G} r ' r ,
Everett Oliver ft. ft. k % Lr L.L.; F.-Li
Facility/Owner Name Facility ID#(if applicable) . ft. ft. S E P 2 2 2023
Cascade Trail, Nebo, 28761 ft. ft.
Physical Address,City,and Zip ft. ft. h r ,Q('t./ia sorG•'r• 'ag Ui:#t
McDowell 164700218137 i1:RR;ftARX5,':"6__ , >,,,.,A. r: ,'
County Parcel identification No.(PIN) this well was self et.rtified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laUlong is sufficient) 22.Certification: I
N W 07/18/2023
6.Is(are)the well(s) Permanent or Temporary Sigma a of Cc edgh ontmctor Dace
8y signing th.Jinni,I hereby ce.rth•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or r3No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and erplain the nature q/'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 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 1'`
9.Total well depth below land surface: 265 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifd/erent(example-3 a 200'and 2 r0100') construction to the following:
10.Static water level below'top of casing:20 (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: P
(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) 30 Method of test: RIG 24c.For Water Supply&Iniectil n'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 die county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016