GW1--03498_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES —I
FROM '10 DtSCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for maid-cased welk)OR LINER(if al) kable)
CLYDE SAWYERS& SON WELL&PUMP INC FROM To flAME IRK THICKNESS MA'IERIAI.
+1 rt. 115 ft. 6.25 ill- #21 PVC
Company Nan1c 1 C
W23/24-0 14V 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable sell construction permits(i.e.UIC County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): fI ft. in.
b
ater Supply Well:
►7.SCREEN
FROM 10l1 t:T 1 2 sTOT SIZE THICKNESS NI 1 RioLU.
Agricultural Municipal/Public It. ft. DI\ in,
Geothermal(Heating/Cooling Supply) Q Residential Water Supply(single)industrial/Commercial
Irrigation
fr. fr. in
❑Residential Water Supply(shared) 18.GROUT
IBO\I -r(1 Ni Ii'RI(I. F\UPI St'h:>IP\T NFIIIOII&A\101�\1
Non-Water Supply Well:
o ft. 20 It• Bentonite Pumped
Monitoring
Injection Well:
®Recovery CI ft. Cap Top with Bentomite chips
ft. It.
Aquifer Recharge ®Groundwater Remediation
t9.SAND/GRAVEL PACK(if applicable)
1\yuifer Storage and Recovery OSa1inity Barrier fKtl?I It) ?I,ArERU1. I:VI I'LACL?It:�T'11ETHOD
Aquifer Test OStormwater Drainage it. ft. -
()Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,20.1)RILLING LOG(attach additional sheets if accessary)
QGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM 10 DESCRIPTION(color,hardness,soil/rock type,grain sit,etc.)
0 ft. 115 ft. OVER BURDEN
3-20-2024 115 ft• 445 ft• GRANITE ►'^
4.Date Well(s)Completed: Well ID# *...��.
Sa.Well Location: ft. ft. t LP L;VE It)
EQUITY TRUST CO CHARLES MCDEVITT ft. ft. JUN 1 2 2024
Facility/Owner Name I aulityID#(if applicable) ft. ft.
OLD PLEMMONS ESTATES LOT 2&3 MARION, NC ft. ft. Irionrrc.Cyern i*-r.r, :.y Ursa
Physical Address,City,and Zip ft. ft. trfsW S'i
MCDOWELL 068700952547 21.REMARKS
County Parcel Identification No.(PIN) Well was Sellt certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: — '
(if well field,one Iat/long is sufficient) 22.Certification:
N W 3-26-2024
6.Is(are)the well(s)C Permanent or OTemporary Signs a of Cer ed ontranor Date
By signing th ornt,1 hereby certiji'that the well(s)INS(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EDNo with 15A NCAC 01C.0100 or 15.4 NC'AC(12C'.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 ibis record has been provided to the sell owner.
repair under f111 remarks section or on the back of this firm.
23.Site diagram or additional well details:
R.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 i 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: 445 (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: 35 (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 Iniection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: RIG 24c.For Water Slimily&Iniection 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: 35 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