GW1--01155_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. 1
NC Well Contractor Certification Number
1S#OWEI G'�A51 tform'alii a sa ells):OI61INERe(irapppliesbfe)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 68 ft. 6.25 #21 Pvc
Company Name 1`r iNNERTCASU4Gr AR TOl111 G(q"euibermal close'd=lgop
EH25169 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. : in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) -
ft. ft. in.
3.Well Use(check well use): t' 5CREEN „ arx<'° , A
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) ft. ft. m,
❑Industrial/Commercial ❑Residential Water Supply(shared) 7R C*RUt17 - " . i ,
FROM TO MATERIAL EMPLACEMENT METHOD)&AMOUNT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft. '
DAquifer Recharge 0 Groundwater Remediation 19 8:ArNIi/C12t'4?ELS?1'ACK(it.agplieal`fe$ . "r;M
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test 0 Stormwater Drainage .
ft. ft. i
❑Experimental Technology 0 Subsidence Control '
10134 ;TANOI;VCR(aTta'e fifilditionaiiiiri ilif ` tii ''
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock tape,grain size,era)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 68 ft. j ' OVER BURDEN
11-15-2023 68 ft. 465 ft• i GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. r.,. ,R,. ;.,- ---,,
5a.Well Location: ft. ft. I' 6 it—�.,,� t _, ,r
GAVIN VENTURES/JOHN DAVIS ft. ft. Eh
Facility/Owner Name Facility Wit(if applicable) - L0�
ft. ft.
4601 COXE ROAD TRYON, NC 28782 ft. ft. rfhcfmatt:n,'*-r.•,7.;; Ur,.?
Physical Address,City,and Zip
POLK P115-52 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 lat/long is sufficient)
N W 11-30-2023
Signature of ertified Well Contract I, Date
6.is(are)the well(s): OPermanent or OTemporary By signing f y /i, (� (were)si win g this form,1 hereb•certi that the wells was were constructed in aceorthmee
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo 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: 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
9.Total well depth below land surface:465 (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(400'and 2(4)100') construction to the following: i
10.Static water level below top of casing:
80 (ft.) Division of Water Reources,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
(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&Injecti I n Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county ealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I ,