GW1--06167_Well Construction - GW1_20230922

,Pant Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L'Well Contractor Information:
Kolby Sawyers 44._WAT1sR,ZONES > u'4,v ..iC,n�. _ .__ S
FROM TO DESCRIPTION
Well Contractor Name ft R
4471-A ,
ft. ft.
NC Well Contractor Certification Numbcr
13.:01117ERi MING;(fo`r.multi CUS1 1411t);OR;LINRI(if i p"7icable)r. r,: .
CLYDE SAWYERS&SON WELL& PUMP INC PROM TO DIAMETER THICKNESS MATERIAL _
+1 ft• 140 ft• 6.25 i, in' #21 PVC
Company Name
W23_031$ ;=76.INNER CASING,OR,TUHINGIgeotherniutctosed400pr -_"' , , •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constntctiar permits(i.e.UIC.County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: s1?.SCREEN . ,.-,, f , <, ,,- __.`- _ •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1L
*Agricultural 0Municipal/Public ft. ft. in.
- aGeothermal(Heating/Cooling Supply) X0Residential Water Supply(single) ft ft. in.
It Industrial/Commercial OResidential Water Supply(shared)
.18 GROUC ...V7,;Q s �_ 1 .,:_ .,
jl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL 20 ft. Bentonite Pumped
ill Monitoring 0Recovery ft. ft. Cap Top with Bentomite chips
injection Well: ft. ft. ;
*Aquifer Recharge _,:Groundwater Remediation
79sS.AI D/GRAVEL-P,ACK Of applicable)....,%c . ,-+,r
It Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
SI Experimental Technology DSubsidence Control ft. ft. .
II Geothermal(Closed Loop) OTracer 20+DRILLINGEOG(af(ach additional sbeets'if necessary)W„ , i .
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
0 ft. 140 ft. OVER BURDEN
4.Date Well(s)Completed:07/12/2023 Well ID# 140 ft• 305 ft. GRANITE
i`�'
It. IL .a g„„ 0 r Sa.Well Location: , ,( IL...Y 1.' J
James Goldsmith ft. ft.
Facility/OwncrName Facility lD#(if applicable) ft. ft• SEP 2 2 2023
1341 Mack Noblitt Rd, Old Fort 28762 ft. ft.
iF zt!:::n?:':-^w* e'.2 Ufs
Physical Address,City,and Zip ft. ft. i. Ti ,
:�21;;REMARKS,,. „
McDowell 066800509809 �: ,_ _ f ..- 4 ..,. ..-,,_:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certification:
N W 07/14/2023
6.Is(are)the well(s) Permanent or Temporary Signs a ofCe cd ontractor Date
' By signing rb treat,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 'XDNo with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infirntation and explain the nature of the copy of this record has been provided to!the well ouster.
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
9.Total well depth below land surface: 305 (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 rt,200'and 2@I00) construction to the following: ;,
10.Static water level below top of casing:20 (ft.
Division of Water Resources,Information Processing Unit,
I(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: constntction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Infection.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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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