GW1--05620_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kol by Mitchel Sawyers Isla A'rictzIONPsaWaW h r.; ,M:f Fig,:
FROM TO _ DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft. / I
NC Well Contractor Certification Number
CLYDE SAWYERS & SON WELL & PUMP INC 15';Ut)LERG tit,tforilu►d enEcEi�enI THIICvNESttnp tlMATERI .:.;:s s
FROM 10 U14MN INR � IHILhNF SS M41F;12111
+1 ft 70 ft 6.25 II in. #21 PVC
Company Name
OSS-2024-0416 IteiNoutiois i obt Ttroitst(r;anti,!waii9ort oiii ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft' ft. ,'in.
Water Supply Well:
h 17 $i RZ LN�)' N � �VE S.ti0.*WIW . Sc n6
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalA4unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single)industrial/Commercial Irrigation
ft. ft. in.
Residential Water Supply(shared) tg;.GROUT. `; ids ` , ,s w s
FROM TO [MATERIAL EMPLACEMENT METHOD&APIOUN'I'
Non-Water Supply Well: 0 ft. 20 ft. Bentonite; Pumped
Monitoring
Injection Well:
Recovery ft. ft. Cap Top with Bentomite chips
ft. ft.
Aquifer Recharge El Groundwater Remediation
ft9 SANOiC:R�k1TE' PSCI (ifi4jilkiiblif r 's' N `. a y .014 y.
Aquifer Storage and Recovery �Saluury Barrier PROSE TO MATERIAL . EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage ft. ft.
Experimental Technology8
Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .,.2(tViti 7t i1V01 G.t1itae iiilditi itilieetssfnecessari) '•NIMCKIMVin
FROM TO DESCRIPTION(color,hardness.soWUrock type.grain size.etc.)
OIGeothermal(Ueating/Cooling Return) 0Other(explain under#21 Remarks) 0 ft. 70 ft. OVER BURDEN
4.Date Well(s)Completed:8-1-2024 Well iD# 70 ft. 225 ft. GRANITE
5a.Well Location: ft. ft.
AMY& MICHAEL DRYER ft. ft. ,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
246 MISTY MEADOW LANE ETOWAH, NC ft. ft. I
Physical Address.City,and Zip ft. ft.
HENDERSON 9538235769 2I:;REV1tquK5; N IM .-° A. : ITA:..W
County Parcel Identification No.(PIN) WFI I WAS SFl F CFRTIFIFn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
dwell field,one lat/lon is sufficient) ;.
C f 22.Certification: l'
N N' 8-20-2024
6.Is(are)the well(s) IIX Permanent or OTemporary Signa a of Ler ed onlraclor Date
By signing lb. aunt.I hereby certifF that the wells)Fun ( Jl�glls ktetiftgr�•cordance
7.Is this a repair to an existing well: 0 Yes or ix No with 15A NCAC 02C.0100 or ISA IVCAC 02C.0200 Well C pn.snvstion Sran4luri t err t1w4a7
If this is a repair.fi l out knon7a well construction information and explain the nature oftlre colry of this record has been provided to the yell owner. J ' .b....fir'L.; b�11..IZ„�
repair under 1121 remarks section or on the back of this form. n
23.Site diagram or additional well details: C P
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional ell si e detain well
construction details. You may also attach additional pa yes ifpeece r
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells Ifkrp-Y,:.V.fil. '•x*,ArNi UM
drilled: I SUBMITTAL INSTRUCTIONS ' M/ [3rrvt`lyA+✓G
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijfcrent(example-3@200'and 2(/q/00') construction to the following: I
10.Static water level below top of casing: 50 (ft.) Division of Water Resource,information Processing Unit,
11.water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6. (in.)(in.) 24b. For Injection Wells: in additi�onfto 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
(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) 6 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submitlotie copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 22 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