GW1--01169_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers fla t air It il+rl s ; Vit f,,. � R4
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I j
4471-A
ft. it.
NC Well Contractor Certification Number
Wetk`figHOtil+fG(formiitd•caw`"s'iiix-fveitsibkxL!Nk(eftFitr1tenTileM~Mk
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAME MR THICKNESS MATERIAL -
+1 ft 35 ft• 6.25 1tl #21 PVC
Company Name
OSS-2023-0759 To:"INl\{ER, A-SIN4",!i13,1'TjIIINL'1,(ecufhornialiclasetf Poop`` ?. :
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,Stare.Variance,etc.) ft. ft. ' . in.
3.Well Use(check well use): ft. ft. I in.
f
Water �, `,
gri Supply Well: X1.r1.00RER, ', < ,... .t. .
6
FROM TO DIAMETER r SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. in.
Industrial/Commercial Residential Water Supply(shared)Pp Y( BiCIYt)lU1'���q�.x:�,�w,:�`����,'w �i �.� �� ��v�`.:�; '
irrigation FROM TO MATERAAl. E:MPI.ACEMENT METHOD&ASIOUNT
Non-Water Supply Well: o ft. 20 ft.
Bentonite Pumped
Monitoring Recovery ft. ft. Cap Top with Bentomite chips,
Injection Well:
Ita
Aquifer Recharge ID Groundwater Remediation ft. ft.
Aquifer Storage and Recovery
Salini ter Dr FROM J TO PACIf(if applicable) .. `,
q g ery ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stonnwater Drainage ft. ft. 1.
Experimental Technology 0Subsidence Control ft. ft. I; '
(Geothermal(Closed Loop) ®Tracer 140A);KIT GuLE iGY{aitacli adlitiV allrshee i`ifneressarii ': tw ':"
FROM TO DESCRIPTION(color,hardness,soil/rock tvpc,grain size,etc.)
(Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 35 ft. OVER BURDEN
4.Date Well(s)Completed: 1-18-2024 Well ID# 35 ft. 765 ft' GRANITE.
5a.Well Location: ft. ft. _w _
COUCH 53 LLC ft. ft. ^': k.,;i:r; ` ,,_I✓
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
954 MOUNTAIN GROVE LANE FLETCHER, NC 28732 ft. ft. I-tb LOZ4
Physical Address,City,and Zip ft ft. Ii for Tf'.4Eza Puri w4ing UM
HENDERSON 966199006
y 112EtGTxlftTz.S ;. . „ -- : .tt M .lr„4V
County Parcel identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certification:
N W 1-19-2024
6.Is(are)the well(s)�I% Permanent or Temporary Sigma a of el ed onhudor Date
By signing th Arm,1 hereby tier*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or % No with 15A NCAC 02C.011)1)or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature oft/re copy of this record has been provided toithe well owner.
repair under#21 remarks section or on the back of this form. '
23.Site diagram or additional well details:
8.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 alsoiattach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 765 (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 ry)00') construction to the following:
10.Static water level below top of casing: 280 (ft.) Division of Water Resources,information Processing Unit,
(/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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: ii6
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service denier,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&injection 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: 35 completion of well construction tti the county health department of the county
where constructed.
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016