GW1--04832_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: �—
1.Well Contractor Information: J
Kolby Mitchel Sawyers WOO
FRO?I TO DESC'RII'LION
Well Contractor Name It. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If op kable)
CLYDE SAWYERS& SON WELL &PUMP INC FROM To D1.5MF:TER THICKNESS LM1
+1 ft. 56 rt. 6.25 in• #21 VC
Company Name
W23/24-0147 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: FKonI TO DIAMETER THICKNESS M.1'IEK41l.
List all applicable well construction(permits ti.e.UIC.Counrn,State.Variance.etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO D1.SMF:TI/R SLOT SIZE "IIIICK\E5S M4 TERI:U.
13 Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Q Residential Water Supply(single) ft ft. in. I — —
°industrial/Commercial OResidential Water Supply(shared) tg,GROUT
°Irrigation FROM '10 MtTF.RI AT F NI PI.AC'I:MEN I NIErn0D&4MOC NI
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
0Monitoring °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 mom To AlATERIAI. EMPI..SCESIENl METHOD
Aquifer Test °Stomrwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
1 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) _
FRCNI TO DESCRIPTION(color,hardness.sail/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks)
0 ft. 56 ft- OVER BURDEN
4.Date Wells)Completed:7-19-2024 Well TD# 56 Ct• 205 Ct• GRANITE j' _
Sa.Well Location: ft. rt. FA.' t..t k..t 1I l._
DORIS DAVIS iI. ft. AUG 1 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
470 BULL WALKER ROAD OLD FORT, NC 28762 rL rt. Ittfv.+.?i4.•'+;C_/a'r I ki(
Physical Address,City,and Zip ft. ft.
MCDOWELL 064800937438 21.REMARKS
County Parcel Identification No.(PIN) WFI I WAS SFLF CFRTIFIFD —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-
(if well field,one Iat/long is sufficient) 22.Certification:
N W' 7-23-2024
6.Is(are)the well(s)0Permanent or °Temporary Signa a offer ed ontractur Date
By signing Ih Deno,1 hereby certiJj'that the wellls)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or )t°No with 15.4,VCAC II2C.I)/OO or 15A NCAC 02C.021)1)Well Construction Standards and that a
If this is a repair.fill out known well construction hyimnation and explain(the nature of the color of this record has been provided to the lied owner.
repair under 021 remarks section or on the back r f 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 wail 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: 205 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-9(N200'and 2@lOO') construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,information Processing Unit,
i/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) 50 Method of test: RIG 24c.For Water Suooly&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 6W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016