GW1--04834_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-1) 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 15.OUTER CASING(far multi-cased wells)OR LINER(if apRIkable)
CLYDE SAWYERS&SON WELL&PUMP INC FROM 'ro OIAMEI'FR THICKNESS M4'rE:R1A1.
+1 ft. 76 fl. 6.25 in. #21 PVC
Company Name
SW23-03 5 16,INNER CASING OR TUBING(geothermal clotted-loop)
111
2.Well Construction Permit#: FROM TO I1L4F.TER THICKNESS 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 'Pg
FROM to DI-AMEI FIt .I Ott slit.: l tuC KNI.s St sit Rr SI.
Agricultural ©Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) el Residential Water Supply(single) —ft. I ft. I in.
Industrial/Commercial ®Residential Water Supply(shared) 18.GROUT
irrigation FROM I 'rO 1I Orr.RI SI_ F NIP!.A('FMTN I Mr'Ilion&41lOt'fir
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
Monitoring ®Recovery ft. ft. Cap Top with Bentomile.chips
Injection Well: - —
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM 'ro m S I FIU St. EMPLACEMENT ntL,THOD
Aquifer Test OStonnwater Drainage ft. rt.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soitirock type.grain sin,etc.)
QGeothemml(Heating/Cooling Return) OOther(explain under#21 Remarks) o ft. 76 ft. OVER BURDEN
4.Date Well(s)Completed:7-10-2024 Well ID# 76 ft' 185 ft• GRANITE
5a.Well Location: ft. ft. :.. .,i`. R l f r"�
DAVID ASHLEY&TIFFANY BOONE ft. ft. AUG ` 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
117 BIGGERSTAFF DRIVE NEBO, NC ft. tt. it fVariti,;:-a ?-r'304;:' tf?`.i1t
DiNC..1,2.3
Physical Address,City,and Zip ft. ft.
MCDOWELL 165800176379 21.REMARKS 1_,.
County Parcel Identification No.(PIN) SFLF CERTIFY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W 7-17-2024
6.ls(are)the well(s)I% Permanent or OTenlpnrar} Sig e of er ed onlranor Dare
Er signing th on,i.I hereby certi*j*that the well(s)BUS(were)constructed in accordance
7.Is this a repair to an existing wen: OYes or EiNo with 15A NCAC 02C.010X)or ISA NCAC 02C'.(1100 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 tell owner.
repair under#21 remarks section or on the back if this firm.
23.Site diagram or additional well details:
A.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 wells list all depths if different(example-3@200'and 2@,@1110) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If Rater 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) 10 Method of test: RIG _ 24c.For Water Suooly&Injection 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: 20 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