GW1--02969_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD ! P�InfiFgrrrl
CO (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Kolby Mitchel Sawyers A4.twmro zoNEs wmo,. s _,w .n . . u, ;: . „t -J
Well Contractor Name FROM TO DESCRIPTION _ ' ` '
4471-A ft. R. I
ft. ft.
NC Well Contractor Certification Number ';S;'piI'CERICASfNG(foi;+ntilb rasktt,tvelli);OR'l[NER_(tfaip'pllteable), :z ,
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER' THICKNESS MATERIAL
+1 ft. 36 ft- 6.25 I, in. #21 PVC
Company Name
OS8-2023-1487 ,,16.1.NNER.:0$`1lkG;OR.TU131Nt1 ealheriitaltIused►gyp)'_ / r. .. < '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),State.Variance.etc) ft. ft. 1, in.
3.Well Use(check well use): ft. ft. i, in.
Water Supply Well: r17.-SCREEN a. =`e x .0 A�-. . V
FROM TO• . DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic• ft. ft. in.i '
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial DIResidential Water Supply(shared) 1S:GROUT <'
!Irrigation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentomite,, Pumped
*!Monitoring EDRecovery • ft. ,ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
1 Aquifer Recharge OGroundwater Remediation
.19.:SANA/GR VEL?PACK(if5piplieahle) `. ',` a; _ 't,, ..o..
•i Aquifer Storage and Recovery OSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
I Aquifer Test 0IStormwaterDrainage ft. ft.
I Experimental Technology )Subsidence Control ft. ft.
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*Geothermal(Closed Loop) ()Tracer '20:`DRIGLINCrIIat)Cs(atitieli adtlttiiiiikilieetsSf eiecessary) a nR 031 .
R{Geothermal(Heating/Cooling Return) EllOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
0 ft. 36 ft. OVER BURDEN r...,,.
4.Date Well(s)Completed:02/28/2024
Well ID# 36 ft• 565 ft' GRANITE 1 t ,,.:r Z,.i, l r ,..,', -
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Sa.Well Location:
ft. ft. i MAY 1 ' 2024
EDWIN BRINSON/JOSH ISRAEL ft. ft. I
Facility/Owner Name Facility ID#(if applicable) ft. ft. i, lr/v rry:v`er t rr.c_�r�;^o-yl Ui'
354 BRADLEY MTN RD. ft. ft. D'iriul;)%
Physical Address,City,and Zip ft. ft. I
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Henderson 0600701518 �;2i:'REMARIc5«:,,&=7-.1.-1,i--v:.r: t, ,x�,N._.. . , ,ZM . __ t7.,.
County Parcel Identification No.(PIN) Well was self certified
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: 1,
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N W 03/05/2024
6.Is(are)the well(s) Permanent or .Temporary Sigtra a of Ce edontracror Date
By signing th form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Eit No with 15A NCAC 02C.0100 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 wellidetails:
S.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
9.Total well depth below land surface: 565 (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:
10.Static water level below top of casing:40 (ft.)
Division of Water Resource's,Information Processing Unit,
If waterlevel 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
12.Well construction method: ROTARY above,also submit one copy of this,form within 30 days of completion of well
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) 2 Method of test: RIG 24c.For Water Supply&Iniectiol Wells: In addition to sending the form to
PILLS the address(es) on above, also submitll e copy of this form within 30 days of
13b.Disinfection type: . Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016
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