GW1--02962_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
Kolby Mitchel Sawyers I4.ryAllERzcrr>s, t .e.::. .-`----WM. . .
Well Contractor Name FROM TO DESCRIPTION
ft ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15,.UU'I'kltiCA$1tVG(forutti-casetl:ivells)17RIsINER:(if-sp icabte)t=
CLYDE SAWYERS&SON WELL &PUMP INC FROM TO DIANIb 1'ER THICKNESS 1 MATERIAL
+1 ft. 69 ft. 6.25 m #21 PVC
Company Name
OSS-2023-1203iM.6.;11NNEWCASiNCVRIiTLtftiNaW.etlieiliia'tiek:tkdoDPMMMMMM
2.Well Construction Permit#: FROM TO DIAMETER - THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. ' in.
3.Well Use(check well use): ft ft. ' in.
Water Supply Well: ,;17�-SCREEN.1-:m -.-n :�:x:,e.,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
II Agricultural EiMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) p Residential Water Supply(single) ft. ft. inJ
*i industrial/Commercial , DResidential Water Supply(shared) i8 GRUUT w Y
I Irrigation FROM , TO MA't'ERIAI. EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite Pumped
il I Monitoring DRecovery ft. ft. • Cap Top with Bentomite chips
Injection Well: '
ft ft.
i Aquifer Recharge D Groundwater Remediation 19,-SANDIC3RATELPAGKifapplicati1e) .-...:..
*iAquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
!Aquifer Test DStonnwa ter Drainage ft. ft.
Experimental Technology - 0 Subsidence Control ft. ft. ,
*Geothermal(Closed Loop) oTracer 20 aDR1LLINGI OG(attaefisadditianatsheecsafiiecessary) =, -....; V A.
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
at Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 69 ft. OVER BURDEN
4.Date Well(s)Completed: 02/12/2024 Well ID# GRANITE
69 ft• 225 ft.
5a.Well Location: ft. ft. rt-- r _^
CMH Homes ft. ft. ! le V ,. 1:::i kri :1-s,
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 1 2024
59 Alberto Way, Lot 4 ft. ft. i
i
Physical Address,City,and Zip ft ft. . I'r1: :77..cV i a:i'`-•^:^44 FY3 jr,I
Henderson 0602622170 2t'f tEmAR smaiMERMVM in i:V'
County Parcel identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I.
(if well field,one lat/long is sufficient) 22.Certification:
N W I 02/20/2024
6.ls(are)the well(s)J% Permanent or OTempurary Signa a of er ed unit-actor Date
By signing th orm,I hereby cerrifj�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [J Yes or E:11No with 1SA NCAC 02C.0/00 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 of the copy of this record has been provided to the 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 also'attach additional pages if necessary.
drilled: ' SUBMITTAL INSTRUCTIONS
225'
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@200'and 2 ,100') construction to the following:
20 I
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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ROTARY above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 5• Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS 15 the address(es) above, also subunit Ione 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