GW1--07715_Well Construction - GW1_20231122

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WELL CONSTRUCTION RECORD i
For Internal Use ONLY: i
This form can be used for single or multiple wells 4
1.Well Contractor Information:
Derrick Heath Sawyers '14.WA'1ERZONE$ ..a . _. ' :'' ,:, ___ , , _3
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
2436-A ft. ft.
NC Well Contractor Certification Number ,15.'OUTER;CASING(for'iulti caseiPiVells)OR LINER(ifahpliea6lo).-' _ •-- -_---':
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 121 ft- 6.25 I 'in' #21 Pvc
Company Name 16.INNER Cr SING OR`TUBING(geottieratat-closed loop)': _
W23-0008 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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List all applicable well permits(i.e.County.State.Variance,Injection,etc) ft. ft. in.
3.Well Use(check well use): %PhSCREEN ,. 0 . a_-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) FiResidential Water Supply(single) ft, ft. in: •
❑Industrial/Commercial ❑Residential Water Supply(shared) `1$,--GROUT ,.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 20 Bentorite Pumped
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: . ft. ft.
❑ quI erRecharge ❑Groundwater Remediation s19.,SAND/GRAVEL,PACK(if applicable)';° . --- -" _ __
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. 1
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '
20.xDRILLINGLOG(attach additional ssheets:if necessary) :°'
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,soiVrock type,grain size,etc.)' .r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 121 fL 1 OVER BURDEN
09/21/2023 121 ft. 605 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. T -... .`
2
5a.Well Location: ft. ft. '.. 'iti.,:,i; 41 r..)
JRO Investments LLC ft. ft.
NoN 1H' c� `
Facility/Owner Name Facility ID#(if applicable) ft. R. V ` ���
510 S Vineyard Village Dr., Old Fort, 28762 -ft.-
; , „-
ft. T' l ,f
Physical Address,City,and Zip
McDowell 066800594092 This weli,was self certified.
County Parcel Identification No.(PIN) !
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient)
N N 09/27/2023
Signature of edified Well Conlracto Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA MAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to'the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane construction,you can ,
submit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All.Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2 a 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 ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm)2 Method of test; RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form l within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water esources Revised August 2013
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