GW1--02966_Well Construction - GW1_20240513

Pririt Form
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: .
1.Well Contractor Information: I
Kolby Mitchel Sawyers $I4:wATEr zoNEs-
DESCRIPTION
R'e1lContractor Name
FROM TO
4471-A fr. ft.
ft. ft. I I
NC Well Contractor Certification Number
.tS,:Ut!'t'CRCASIIYG:(forioutti-easetiiveiis)[lit,;lNfiR(iEsppl3cabk); • ''
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER b THICKNESS MATERIAL
+1 fL 25 ft 6.25 I. in #21 PVC
Company Name
OSS-2022-0304 18:>INNEWCAstrrc:+JR:TURINGticbtherm>il bged ioonM
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): fL ft. in•
Water Supply Well: •
FROMREE TO DIAMETER DIAMETER 4�wSLOT SIZE THICKNESS MATERIAL `
•Agricultural OMunicipal/Public ft. ft. in.
•Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. in.
•ITndustrial/Commercial OResidential Water Supply(shared) 1&;GROU f` ::... a
I Irrigation FROM TO MATERIAL. : EMPLACEMENT METHOD&AMIOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite Pumped
*Monitoring nRecovery ft. ft. Cap Top with Bentomite chips
Injection Well: •
ft. ft.
!Aquifer Recharge OGroundwater Remediation
• .49.,SAND/C2I>AVE PAC&TtFappli die)_ M -. ---- :; M- ..._a:
*Aquifer Storage and Recovery 0Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
[Aquifer Test 0 Stomlwater Drainage ft ft. •
BExperimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 21iz-1)RI GIING:I OG{attacfi-addihoalsheeis a(riecessar}) ?� .
FROM TO SIPION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft 25 ft.
DE OVERCR BURDENT
4.Date Well(s)Completed: 01/22/2024 Well ID# 25• fL 405 ft.
GRANITE
5a.Well Location: ft ft.
Christopher Miller ft. •ft. r"'`--,;' f1.7"--7
Facility/Owner Name Facility ID#(if applicable) ft. ft.o.
180 Ridgeview Dr. ft. ft. MAY 1 • 2024
Physical Address,City,and Zip ft. ft. it A-.:•x•;.•1 s.y ir3"t F:` °y".-r..
Henderson 9661861472 1 R>♦MARKS. -.---.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification: •
N vv � 02/22/2024
6.ls(are)the well(s)0X Permanent or Temporary Signa a of er ed ontractor Date
By signing th brim 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or 0No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0201)Well Construction Standards and that a
If this is a repair.fill out known well construction infonnation and explain the nature of the copy of this record has been provided touhe 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
405'
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 difierent(example-3@200'and 2@l00') 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 n.
(i ) 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.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
• e,
13a.Yield(gpm) 4 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: 15 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016