GW1--07475_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14AVAt..WZONES ! _
FROM TO DESCRIPTION
Well Contractor Name ft. ft. -
4471-A ft. - ft. i .
NC Well Contractor Certification Number leoli.' ET ASIIYCri OWi unit ased: elli)i7 etINElltgi p Icatit"iy:��
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER THICKNESS MATERIAL -
+1 fL 84 f• 6.25 in" #21 PVC
Company Name �y
WP23-099 MIN.NER,CrAgiX:,OR-tUBtNC{Rcotherrmflt<clased46131)" ' ?
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pens its(i.e.UIC,County,State,Variance,etc.) ft ft. ',' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO _ DIAMETER SLOT SIZE THICKNESS S MATERIAL
l Agricultural E3Municipal/Public ft. ft. in.
*!Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. ft. in: '
aiIndustrial/Commercial ®Residential Water Supply(shared) i$ iGRQUP , - ,,tom
i irrigation FROM TO • MAT ERIA I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 fit' Bentonite Pumped
"'Monitoring Recovery ft ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
IlilAquifer Recharge ()Groundwater Remediation
14::^SA14111G1t(f ELpACIf(if jsti&li) 6ss " ,
*Aquifer ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
]♦lAquiferTest ®StonnwaterDrainage ft • ft. 1
) !Experimental Technology El Subsidence Control ft. ft. ,
)N'Geothermal(Closed Loop) ®Tracer fleDRILIANGIOafiffiehiiddidirii1Wifilfireillifii4-_
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
a Geothermal(Heating/Cooling Return) 13Other(explain under#2I Remarks)
0 it• 84 ft• OVER BURDEN
4.Date Well(s)Completed: 11-7-2023 Well ID# 84 ft 385 ft' GRANITE
_5a.Well Location: ft. b,V,,Cr_ 4.f ti i
Austin Galloway ft. ft. ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. NOV 2 o 2023
937 Shoal Creek Balsam Grove NC 28708 ft. ft. Iri z.;;:<..i'n ; .i:,1 i�ril
Physical Address,City,and Zip ft. ft. I''': :_YDCa
Transylvania 8546-72-4813-000 Z2YItEitiIMIK.s n.: - ..
County Parcel Identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lon is sufficient)6 22.Certification:
N W 11-8-2023
6.Is(are)the well(s) Permanent or OTemporary Signa e of et ed onouctor Date
%
6y signing th Orin,1 hereby cerrifj'that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 0Yes or ()No with 15A,VCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
([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 nell 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'
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 ifd(erent(example-3@,200'and 2 a,/00') 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 ,
(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) 5 Method of test: RIG 24c.For Water Supply&lnieetion Wells: in addition to sending the form to
the address(es) above, also subniit1one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction {o the county health department of the county
where constructed.
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016