GW1--04806_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM 'to DESCRIPTION
Well Contractor Name ft. ft.
4471-A
rt. fi. I
NC Well Contractor Certification Number IS.OUTER CASING(far multi-cased wells)OR LINER(if ap fable)
CLYDE SAWYERS & SON WELL & PUMP INC FROM '1'0 DIAMETER 'THICKNESS MA'rf:RIAI.
+1 ft. 105 ft• 6.25 in- #21 PVC
Company Name
SW22-0040 1(1.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIME TER TIUCKNESS MATERIAL
List all applicable well construction permits li.e.VIC,County,State.vuriunce.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN i;
PROM TO DI\METFR SLOT SIZE l'111CKNCSS_ MA TERI AL
()AgriculturaI [3Mlunicipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
()industrial/Commercial Q Residential Water Supply(shared) 18.GROUT
Q11rigation ERos1 'ro NIAIERISt. I'\n'1A('I'wvl \IFuw)D&n>RR\I
Non-Water Supply Well: 0 ft. 20 ft. Benlonile Pumped
0 Monitoring ®Recovery ft. ft. Cap Top with Bentomde chips
Injection Well: -- —
ft. fr.
()Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
()Aquifer Storage and Recovery El Salinity Barrier FRUDI TO MATERAA1. Eau'1 V T.?ILN I METHOD
QlAquifer Test ()Stonnwater Drainage ft. ft.
()Experimental Technology ©Subsidence Control ft. ft.
()Geothemlal(Closed Loop) ®Tracer 26.01411,111%LOG(attach R40109na1 sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soit/rock type.grain size.etc.)
DGeothernal(Heating/Cooling Return) ()Other(explain under#21 Remarks) 0 ft 105 ft• OVER BURDEN
4.Date Well(s)Completed:7-9-2024 Well iD# 105 ft• 185 ft• GRANITE
ft. ft.
Sa.Well Location: i. ,
DONALD TOLLEY ft. ft.
' ` L. t✓ "
Facility/Owner Name Facility ID#(if applicable) rt. ft. AUG11f` 1 1 L. 2024
1099 PADGETT ROAD UNION MILLS NC ft. It.
u...,:.,:... : 3 .-. ,a I .
Physical Address.City,and Zip ft. ft. DI.
t a
_-i
RUTHERFORD 1623207 21.REMAKES
County Parcel Identification No.(PIN) WFI I WAS SFI FSERTIFIED
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one Iat/long is sufficient) 22.Certification:
N H 7-18-2024
6.Is(are)the well(s)C3 Permanent or ®Temporary Sig e offer ed on tractor Date
By signing th Orin,I hereby certi(i'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or ()No with 15,9 NCAC 02C.0/tX)or 15A N(.AC 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 uvll owner.
repair under#21 remarks section or on the buck of this form.
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 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 wells list all depths ifdifferent(example-J(0200'and 2w to(r) construction to the following
10.Static water level below top of casing: 35 (ft.) Division of Water Resources.information Processing Unit,
i/outer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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.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) 30 Method of test: RIG 24c.For Water Supply& lniection 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 CrW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016