GW1--04807_Well Construction - GW1_20240814

Print Form 1
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licahte)
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO 1)11nit PER THICKNESS MAI ERIAI.
*1 ft. 125 ft- 6.25 in. #21 PVC
Company Name
SW23/24-0271 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM 10 II11\IE PER TIII(IsNf.SS M:CI TRIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) II. I't. in.
3.Well Use(check well use): ft• ft. in.
4-'Water Supply Well: 17.SCREEN
FROM tO Ir11ME 1 EH SLOT SI/V TIIIC KNESS MA II HI%I
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) la Residential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18 GROUT
Irrigation FROM TO NI ATFHI11 F%1P1 ACFMFN I"%It 11101)&n%10t N I
Non-Water Supply Well: o ft. 20 It. Bentonite Pumped
Monitoring 0 Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEME7sT METHOD
Aquifer Test DStomtwater Drainage ft. ft.
I'x perimental Technology E3 Subsidence Control ft. ft.
4-1,(icothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROSt TO DESCRIPTION(rotor,hardness.soil rock type.grain,ire,ek.)
OGeothennal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 125 ft., OVER BURDEN
4.Date Wells)Completed:6-28-2024 Well ID# 125 ft• 345 fi• GRANITE
fL ft.
5a.Well Location:
JAMES M HIRST fL ft. :l` R i
Facility/Owner Name Facility Mir(if applicable) ft. ft.
AMYS RIDGE ROAD LAKE LURE, 28746 fL ft. AUb 1 '- 2024
Physical Address,City,and Zip ft. ft. !I
RUTHERFORD 1612094 21.REMARKS 1.'` .: ' ' --.". 2.
County Parcel Identification No.(PIN) SFI F CFRTIFY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
N W 7-4-2024
6.Is(are)the well(s)O% Permanent or ®Temporary Signa e of Cm ed ,ntrsnor Date
By signing th Orin,I hereby certiilY that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or [3 No with 15.4 NCAC 02C.0101)or 1SA NC',4C 02C•.112(H)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 styli owner.
repair under 1121 remarks section or on the lack of this farm.
23.Site diagram or additional well details:
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: 345 (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(4:IOW) construction to the following:
10.Static water level below top of casing:40 (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 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) 7 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: 35 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