GW1--02967_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14i-wATIERzor.r>
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I 1
4471-A -
ft. ft. I I
NC Well Contractor Certification Number iS.:O(#TtR CASING(foc:mutti-cased welts)OR:INtle(ifsp licableyi . ...4....
CLYDE SAWYERS&SON WELL & PUMP INC FROM TO DIAMF tER? THICKNESS MATERIAL
+1 ft 90 ft 6.25 1iit #21 PVC
Company Name .t6:INNER.cASiNC•UR:TUBtNG(geothermiiititsed-loop)`. , MNinmom
OSS-20023-1580 ,.FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
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.
VO
Water Supply Well: 17.�SCREEN .. ...:N - ., e-_ . x: _a .S.>
PP FROM TO _ DIAMETER _ SLOT SIZE THICKNESS MATERIAL
'Agricultural E3Municipal/Public ft• ft. in. '
al Geothermal(Heating/Cooling Supply) En Residential Water Supply(single) ft. ft. in.
I industrial/Commercial OResidential Water Supply(shared) -
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNI'
Non-Water Supply Well: o ft 20 lt• Bentonite Pumped
RI Monitoring Recovery ft. ft• Cap Top with Bentomite chips
Injection Well: ft. ft.
RI Aquifer Recharge 0 Groundwater Remediation
29S tiND/GRAVEL PACK(if applicable) ... :=.
',AquifeI Storage and Recovery 0 Salinity Barrier FROM . TO , MATERIAL EMPLACEMENT METHOD
iAquiferTest 0 Stonnwater Drainage ft. ft-
I
Experimental Technology 0 Subsidence Control ft. ft.
(Geothermal(Closed Loop) OTracer -_20 DRILLING]Ot='(attaeli.additiuualsheets'i€iiecessa . O`�
FROM TO DESCRIPTION(color,hardness,sot Frock type.grain size,etc.)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) 0 ft. so ft. OVER BURDEN
02/20/2024 90 ft. 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
f4 ft. 1
5a.Well Location:
Amanda Moss fI ft. ti k4 _:i.$ V ' , ,)
Facility/Owner Name Facility!IN(if applicable) ft. ft.151 Field Sparrow LN ft. ft. MAY I _. 2024
Physical Address,City,and Zip ft. ft. 11-/5.;-ri F'7,7.r.2.%:.i7.11 r
Henderson 10010868 z1:REivLARK. s M. . ... 1i,ViW'4:W.... ..
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County Parcel identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22.Certification: '
N W 02/22/2024
6.Is(are)the well(s) Permanent or Temporary Signa a of el' ed ontraclor Dale
X
By signing th.Jorm,1 hereby certi,that the we/l(s)was(here)constructed in accordance
7.Is this a repair to an existing well: 0Yes or xoNo with 15A NCAC 02C.0/00 or 1SA 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#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/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
205'
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 ifdi/Jerent(example-3@,200'and 2 a l00') construction to the following: 1 .
20
10.Static water level below top of casing: (IL) 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
13a.Yield(gpm) 6 • 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 toi 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
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