GW1--02960_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14 w rERizoNEsw->- .gv. .... -
FROM TO DESCRIPTION
Well Contractor Name ft ft. l
4471-A
ft. ft. 1
NC Well Contractor Certification Number
t5,.btt1'Eft3GAl;T[+(G(far"inntd-cased<veiis}t7R:;IINBti(if" itcable}"` W
CLYDE SAWYERS&SON WELL & PUMP INC FROM fO DIAMETER 'THICKNESS 1 MATERIAL
+1 ft. g4 ft. 6.25 to #21 PVC
Company Name 22120109393
m13YtYERtASistC.UiI'C[IB[Nft,_(gcofheraittlelosedEaopv m...._... m... ,.:"`-i:
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ;t7 SSOR&EN„--, -. .._. A'' m
FROM TO DIAMETER': SLOT SIZE THICKNESS MATERIAL
II Agricultural 0 Municipal/Public ft. ft. inl! '
1 Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in:
MIlndustrial/Commercial OResidential Water Supply(shared) 1$.:GR"R113 . .,y..x
I irrigation FROM TO MA•1'RRI.A I. EM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o , ft. 20 ft. Bentonite Pumped
a Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft ft.
II Aquifer Recharge • 0 Groundwater Remediation
9.":!SAND/GRAYELETACKNfsikiliahle) ..----. .....: .. .
!Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
j !Aquifer Test OStonuwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) ®Tracer 20-7iR1fL1NG C1 (attaeh additiuiia1 s seefs:itneeessacjl ' . ,,,;
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain stzc,etc.)
Geothermal(Heating/Cooling Return). Other(explain under#21 Remarks) 0 fG 94 ft• OVER BURDEN
4.Date Well(s)Completed: 02/14/2024 Well ID# 94 ft. 605 ft" GRANITE'
ft. ft.
5a,Well Location: l' r ` .<.. 7_^
James Alford ,,
Facility/Owner Name Facility ID#(if applicable) ft. ft. I MAY i r'n24
1037 Davis Mountain Rd ft. ft. _
ft ft. . !ri.,.xx.aa;i�:1 3r,,e 'as"v.', :,h'i
Physical Address,City,and Zip I r',,1,(.2 ,
Henderson 9558084143 xt l OARA( � .s .,.,..MISIMet ... ..x€. F 'z.,tt...�.� .� . -
County Parcel identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W j, 02/19/2024 •
6.Is(are)the well(s)Ix Permanent or 0Temporary Signs a of er ed onhador Date
By signing tlr Orin,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 0No • with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
II-this is a repair.fill out known well construction information and explain tire nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 I 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: 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(4;100') . construction to the following:
20
10.Static water level below top of casing: (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: 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
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13a.Yield(gpm) 1 Method of test: RIG' 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS 3o the address(es) above, also submit one copy of this form within 30 days of •
13b.Disinfection type: Amount: completion of well construction to 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