GW1--02961_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
Kolby Mitchel Sawyers itw,TERzci S r .
FROM TO DESCRIPTION
Well Contractor Name • ft. - ft•
4471-A rL • ft.
NC Well Contractor Certification Number f5..13(frEWCASING(formm itti-cased4iiis):D12':1ANEItli sp ktiblef .
CLYDE SAWYERS &SON WELL &PUMP INC FROM TO DIAMETER THICKNESS M.ATERIAI.
+1 ft. 50 ft. 6.25 ' in. #21 PVC
Company Name
OSS-2023-1318 :16:INt+rER,CAStNc ITILIBINOAtkotneiiiiit hosed loep)_ . -t
2.Well Construction Permit#: FROM TO • DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft• i in.
3.Well Use(check well use): • ft,, ft. in. ' .
•
Water Supply Well: AFRO fREE TO... DIAMETER SLOT SIZEX��� THICKNESS MATERIAL
a Agricultural D1\lunicipal/Public - ft. ft. in,
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
1Industrial/Commercial DResidential Water Supply(shared) 1$f GR013T
i irrigation FROM '1'O MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
MI Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
aIAquifer Recharge IDGroundwater Remediation
i' AND/GRAY L PACLE(tflippllable} _.. . . o
A uifer Storage and Recovery Salinity Barrier n
. MATERIAL EMPLACEMENT METHOD
*I Aquifer Test OStonnwaterDrainage ft. k ft.
j Experimental Technology ®Subsidence Control ft. ' ft.
MI Geothermal(Closed Loop) 0 Tracer ,2UzDRIC1INGIOG:(attiehiddititiiiatsheMsafneressar}):K:
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
aiGeothermal(Heating/Cooling Return) ED Other(explain under#21 Remarks) 0 ft. 50 • ft. OVER BURDEN
02/16/2024 r
4.Date Well(s)Completed: Well iD# 50 ft• 605 ft• GRANITE 6`,.` --4( 7 ; M1F
5a.Well Location: ft. ft. r '�
Robo Investments LLC ft.• ft. MAY 1 2O24
Facility/Owner Name . Facility ID#(if applicable) ft. ft. lr,f „i-r... „
175 Silverglen Way . n tom ^ y �
•
Physical Address,City,and Zip fI ft. i
Henderson 0612365011
County Parcel identification No.(PIN) • Well was self certified
led
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I'
N W i, , 02/20/2024
6.Is(are)the well(s) Permanent or (3Temporary Signa a of er ed ontraclor Date
X
By signing th form,1 hereby cernfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or ElNo with 15A NCAC 02C.0/00 or 15A NCIC`02C'.11200 Well Construction Standards and that a
If this is a repair.fill out known well construction it formation and explain the nature oft a copy of Eris record has been provided to the styli owner.
repair under#21 remarks section or on the back of this form. I
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 also attach additional pages if necessary.
drilled: ' SUBMITTAL INSTRUCTIONS
605'
9.Total well depth below land surface: (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 a,200'and 24/00') 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.
(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
i
13a.Yield(gpni) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submitI one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 15 completion of well construction to;the county health department of the county
where constructed. I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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