GW1--01160_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: y
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1.Well Contractor Information:
KolbyI I
Mitchel Sawyers ,
�14.1•�'A7'LR+ZONtS0�`�'ar :'i�w'AMR?: ,,—,a•.4'W4UT4xW
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A 'ft. ft.
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NC Well Contractor Certification Number a.-
15,.011TER'CAS11Yt(fortau[d casedialls)(112aE11tER'(ifIrticatile)W MM_:
CLYDE SAWYERS&SON WELL & PUMP INC mom 'ro DIAMI r6R THICKNESS MATERIAI.
+1 ft• 130 ft' 6.25 10 #21 PVC
Company Name _ �. v
6,liVN£R.G�ASIRG DRT,UBIIC(cofLerntul;eTa4ed torip}; ' +'
378103-2
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft ft. in.
1jWater Supply Well: 17.:SGRfi1 Nc EEkee w. ,^
FROM TO DIAMETER SLOT SIZE THICKNESS _MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.industrial/Commercial Residential Water Supply(shared) -
gi8.GROtJT� � �:�s�.`��ONAVtR:= sa,� `�c;��. ��:0 �;:�:
irrigation FROM TOalA'I'KNIAI. EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: 0 ft• 20 ft* Bentonite Pumped
MonitoringRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
191SA10/GRAVELTAGK(CaPPli6616 a`� O-., !,4M
Aquifer Storage and Recovery ®Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stonnwater Drainage ft. ft,
)Experimental Technology 0SubsidenceControl ft. ft.
Geothermal(Closed Loop) oTracer &20IDRILLINCTOGViillicliT41dlii6ii t sheuts iffiece iiiii g ik WF R;,Sri.
FROM TO DESCRIPTION(color,hardness,soil/rock type.gram size,etc.)
OGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 130 ft. OVER BURDEN
4.Date Wells)Completed: 12-15-2023 Well ID# 130 ft• 305 ft. GRANITE 7:: , R„.
Sa,Well Location:
ft. ft. F sLA'LeV Lir
KEVIN&LUCIA BARNES/MANIFES ft. ft. FEB 1 D 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
TBD CHAPEL HILL ROAD MARSHALL, NC 28753 ft ft. tllarrnaien Pr::.tc,tn';rs UM
Physical Address,City,and Zip ft. ft. i 6i'vl�lt�Ca
MADISON 9801-37-5029 -'zl;tt>Eti ARILS M, 7 w w Fx 1,4,
County Parcel identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one Iat/long is sufficient) 22.Certification:
N NV 12-18-2023
6.ls(are)the well(s) X Permanent or Temporary
Signs eof er edW -nVador Date
By signing dr farm,I hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or %ONo with ISA NCAC 02C.0100 or 15A NCAC(12C.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#2l remarks section or on the back of this form.
23.Site diagram or additional well details:
R.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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
'
9.Total well depth below land surface: 305 (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 cc,/00') construction to the following: 1
10.Static water level below top of casing: 80 (ft.) Division of Water Resoulrces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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.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) 3 Method of test: RIG 24c.For Water Supply&Injection'Wells: In addition to sending the form to
the address(es) above, also submi one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction to the county health department of the county
where constructed.
Form(1W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016