GW1--07716_Well Construction - GW1_20231122

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WELL CONSTRUCTION RECORD -
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers I4.wAT>Rti° Es
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. 1
NC Well Contractor Certification Number ,15.OITER,CASING'(forinulh cased;wells)OR LINER(if isp Itgahro,, , , ,,o..
FROM TO DIAMETER _ THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 121 ft• 6.25 i in. #21 PVC
Company Name o16 INNER'CAST:NG,ORTUBING`(#eothermal.closed-loop)^, , i
W23-0007 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ' 'in.
List all applicable well permits(.e.County.State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN t _ "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) UResidential Water Supply(single) ft. ft. t I
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT „ ,' _ i". , �':
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft' Bentonite Pumped
Non-Water Supply Well: ft. ft. I' Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEI:PACK'(ifapplicabie) ..,- ' "
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
R. ft. I
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.-DRILLING'L OG(attach additional sheets if necessaryyr„" 4,4..' _.
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 121 ft• I. OVER BURDEN •
09/21/2023 Well ID# 121 ft• 605 ft• I GRANITE
4,Date Well(s)Completed: It. ft.
5a.Well Location: ft. ft. + ]
ft.JRO Investments LLCft. �• '�•:-A =i, a� ;:I �.Facility/Owner Name Facility ID#(if applicable) NOV ft. ft. 2, 2`n`�
404 S Vineyard Village Dr., Old Fort, 28762 �"
Y g ft. ft. Ir'iC.•._. _,._;_ _ lei :i
Physical Address,City,and Zip r r J
t 21,-REMARKS_'t _ -s .l«±:. »:,�-i <r ra,.,s: 9.., `.';
McDowell 066800583681 This well was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field.one 1at/long is sufficient) �I
�V
N W 09/25/2023
Signature of Certified Well Contracto Date
6.Is(are)the well(s): OPermanent or ❑Temporary By g f certify (� ( ) •
signing this form,I hereby that the well(s)was were constructed in accordance
with 1.5.4 NCAC'02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of this record has been provided to the well owner.
1/this is a repair,fill out knonn 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS j
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 if different(example-3@200'and 2@l00) construction to the following:
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10.Static water level below top of casing: 35 (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 tliis form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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)2 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this fom within 30 days of completion of
13b.Disinfection type: Amount: 15 well construction to the county health department of the county where
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Wnterrel ources Revised August 2013
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