GW1--03499_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM 'I0 DESCRIPTION
%fell Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number ER CASING(for multi-cased wells)OR LINER(if on IkabIe)
CLYDE SAWYERS&SON WELL&PUMP INC mom ro DIAMIFTER THICKNESS MAlE:RIAI,
+1 ft. 42 ft. 6.25 in. #21 PVC
Company Name
SW23-0262 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM •ro I)IAMe rr x THIC KNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PROAI IO DI-%MFIFR _SLO1 l7E THICKNESS NI A IlKI41-
OAgricultural ®Municipal/Public ft. ft. in. i
Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in. I
O Industrial/Commercial Residential Water Supply(shared) —
18.GROUT
I1Irrigation FROM ro \I a rE w,,I E\1PI s(tMFN 1 IF 1 HOD&%\lot VI
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
0Monitoring 0Recovery ft. ft. Cap Top with Bentomde chips
Injection Well:
ft. ft.
Aquifer Recharge ['Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery (3Salinity Barrier I FROM i o NIA FERIAE EMPLACEMIENT ME rmot)
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary),
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
Geothermal(Heating/Cooling Return) pother(explain under#21 Remarks)
0 ft- 42 ft. OVER BURDEN
4.Date Well(s)Completed:3-12-2024 Well ID# 42 n' 185 ft• GRANITE
ft. ft. I.., p.� r,,,. ��
Sa.Well Location: `�.r y - �, 1
MAAIKE KWIATKOWSKI ft. ft. f i'� . , ./ {
1,..,L;
Facility/Ownci\Jame Facility ID#(if applicable) ft. ft. JUN 1 2 2024
766 DIRKSEN AVE NEBO, NC ft. ft.
n. ft. Irti'tsrr,.- ,-•1 ii-E ar Jar.
Physical Address,City,and Zipr.,
MCDOWELL 174100621217 2L REMARKS C` .1;,--...I
County Parcel Identification No.(PIN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 3/25/2024
6.Is(are)the well(s)D% Permanent or OTempurary Sig a offer ed ontractor Daic
By signing th bran,1 hereby certifi'that the well(s1 was•(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or Eallo with 15,4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair..frll out known well construction information and explain the nature of the copy of this record has been provided to the wall owner.
repair under#21 remarks section or on the hack of this firm.
23.Site diagram or additional well details:
R.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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well.,list all depths if different(example-.1@200'and 1(d,100') construction to the following:
10.Static water level below top of casing: 30 (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) 15 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one 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(1W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016