GW1--07558_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers t(tcWA7fER/ZONES - . a- . t*jA .F a,a.x. ,..Y i, .,,,s.
Well Contractor Name FROM TO - DESCRIPTION
ft. ft. i
4471-A
ft. ft.
NC Well Contractor Certification Number :15 OUTI'ER!"CAStNG.(fdr`tmilti easddivefs)'ORIINER(ifd`p lteable).'
CLYDE SAWYERS &SON WELL&PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft• 98 ft. 6.25 in.' #21 PVC
Company Name
OSS-2023-1152 ,16.ANNER:rsAMNO,OR iftiNG,Igiethmai.treihied4O n) �.,M. , . � .. .-.._ ;;z
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State.Variance.etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ":17'•SCREEN,.>,,,i' . .. '. -; . <;. ., ...
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural Municipal/Public ft. ft. • in.
0 Geothermal(Heating/Cooling Supply) EE1Residential Water Supply(single) ft ft. in,
0 Industrial/Commercial E3Residential Water Supply(shared) x IS.:GRQ11fi a ., a � z ._, >.<,;b, r ,. ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite 1. Pumped
)Monitoring EjRecovery ft. ft. Cap Top with Bentomite chips
ii
Injection Well:
ft. ft. 1
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery DiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. t't. i.
Experimental Technology OISubsidence Control ft. ft.
OGeothermal(Closed Loop) E3Tracer •;20.DRILLING DG(attachadditianalaheets.ifneeessar) +i
FROM TO DESCRIPTION(color,hardness,soil/rock.type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 010ther(explain under 021 Remarks)
0 ft. 96 ft• OVER BURDEN
10/18/2023
4.Date Well(s)Completed: Well ID# 96 ft, 705 ft• GRANITE!' ' t.rr ' 7 . ,.,, �
ft. ft. i a ,,c,"- ._ ^ t ._4
o . `J
5a.Well Location: i
Lawrence Douglas Marshall ft. ft. 1' NOV
i 2023
Facility/Owner Name Facility DO(if applicable) ft. ft. l'
0 Old Howard Gap Rd., Saluda,28773 ft. ft. I! . I.-"rt'1 -n l;
Physical Address,City,and Zip ft. ft.
Henderson 602003
21::REMrSIIIKS. -, „as.w 5.- {':n::,, , ., x t,:k: '. . i of
County Parcel Identification No.(PIN) 'his well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1'
(if well field,one lat/long is sufficient) 22.Certification:
•
N W i 10/24/2023
6.Is(are)the wlll(s) Permanent or Temporary Signs a ofCe edontractor. I, + Date
By signing th form,I hereby certt&that1the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or oNo with 15A NCAC 02C.0100 or 15A 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 copy of this record has been provided to the well owner.
repair under#21 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 G W-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:705 ft.
p ( ) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths-if different(example-3@a 200'and 2 a 100) construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources;information Processing Unit,
/f slater level is above casing,:use"+" 1617 Mail Service C¢lllt¢I',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) 1 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: 10 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016