GW1--04796_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Kol by Mitchel Sawyers 14.WATER ZONES
FROM TO _ DESCRIPTION
Well Contractor Name
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.OLTER CASING(for multi-cased wells)OR LINER(If ap feeble)
CLYDE SAWYERS &SON WELL & PUMP INC F ROM I0 DI 1 ME FIR CHI(',NI-SS MA T FRIAL
+1 ft. 34 ft. 6.25 III- #21 Pvc
Company Name 101343 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it. it. in.
3.Well Use(check well use): ft. ft. I in.
17 Well: FROMSupply TO DIAMETER .LOT SIZE I'Ii1CK\FS. N1411CRL1L
Agricultural ®Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) l3 Residential Water Supply(single) ft. ft. in.
Dindustrial/Commercial ®Residential Water Supply(shared) 18.GROUT
"irrigation FROM I To I MA['ERIAI. I;NI PI A('F MEN'„METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pumped
°Monitoring ()Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
°Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomtwater Drainage ft. fr.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock rypc,grain size,etc.)
0 ft• 34 ft• OVER BURDEN
4.Date Well(s)Completed: 05/17/24 Well ID# 34 ft• 1005 It. GRANITE
Sa.Well Location: ft. R.
Gregory Graham • ft. ft. -'-- 'e.•t 4 z.....4.)
Facility/Owner Name Facility ID#(if applicable) ft. ft./ A U 1 l3 1 4. 2024
100 Crestwood Dr., Bumsville ft. ft.
tt
Physical Address,City,and Zip ft. a. Di...::.:' 73
Yancey 074900378493000 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 21.( crtitication:
N W 08/01/24
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6.Is(are)the well(s)0 Permanent or OTetnporar}' Signs e of( ed onuanui Date
B)•signing th arm,1 hereby ceri i'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ayes or XDNo with 15,4 NCAC 112C.0/110 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 hack of this farm.
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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1005 (R) 24a.fordayscompletion All Wells: Submit this form within 30 of corn letion of well
For multiple wells list all depths if different(example-3@200'and 2(4/00) construction to the following:
10.Static water level below top of casing: 500 (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.Z5 (in.)
24b. For Infection 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) 1/4 Method of test: RIG 24c.For Water Slimily&Infection 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: 28 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