GW1--01148_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information: I
• Kolby Mitchel Sawyers 14WA IZOK :` : ,
W
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number ;O011'kit ASlfiittifo Alitild.caseiirsveits)itfteMNEtt'(iCarilcable) tW
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO I)I.AME1•ER THICKNESS MATERAAI.
+1 ft. 72 ft" 6.25 l ,m• 21 Plastic
Company Name
W23124-0066 #i6 i1NN)t�tASING1 ittilINUT(g ti lelilai ilss toh ;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countyy,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1VSCRRCN, ' N ' .,�t��",,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
$IAgricultural ®Municipal/Public ft. ft. in,
II Geothermal(Heating/Cooling Supply) fa Residential Water Supply(single) ft. ft. in. •
j�IIndustrial/Commercial ®Residential Water Supply(shared) 18 Gkou 1,,, ' '
I irrigation _FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft• Bentonite Pumped
jai Monitoring ORecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
) I Aquifer Recharge ®Groundwater Remediation
*Aquifer Aquifer Storage and Recovery ®Salinity Barrier 1VAA YD/GRAOPA(3I{t 64ii FROM TO MATERIALA[itN) y'•", ` r '''EMPLACEMENT METHOD
j I Aquifer Test 0 Stonnwater Drainage ft. fr.
j I Experimental Technology 0 Subsidence Control ft. ft.
�iGeothermal(Closed Loop) ®Tracer 11:',AR1T5LANGit(W{atiacfi.aildltidnalheetififanecessa& ,� ..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type.grail size.etc.)
0 ft. 72 ft. OVER BURDEN
4.Date Well(s)Completed: 11-07-2023 Well ID# 72 ft. 185 ft.
pGRANITE,
5a.Well Location: ft. ft. I C I. �r'';a 1 -"" .
Jose Martinez ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. DES 1 9 2024
4392 US 221 N Rutherfordton, NC 28139 ft. ft.
In`;,,-.;,:-;;I:n:', :::•2;..-tins
Physical Address,City,and Zip ft. ft. ' G,rvt.0 t�,-t.
3JC=
Rutherford 1605606 V(zi azE Y 5y' ' '',
County Parcel identification No.(PIN) WFI I WAS SELF CERTTIFIFF)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W I 11-20-2023
•
6.Is(are)the well(s) Permanent or E3Temporaty Signs a of et ed onlractor Dale
X
By signing Ili.form,1 hereby certif'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or %oNo with 1SA NCAC 02C.0100 or ISA 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.
23.Site diagram or additional well details:
S.For Ceoprobe/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 i
9.Total well depth below land surface: 185 (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 a;100') construction to the following:
10.Static water level below top of casing:40 (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 Infection 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.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&Iniection 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.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016