GW1--06622_Well Construction - GW1_20241108

P a f llflt Form
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: ,
1.Well Contractor information:
Kolby Mitchel Sawyers livemmttictonsa , ' v a .. ,.Y
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
I
4471-A
ft. ft. !
NC Well Contractor Certification Number 15 U13TER Olt61Y0(fdiliii titn eased:idelli)`OR*LfNEIle(ifiitp lieabl s
CLYDE SAWYERS &SON WELL & PUMP INC FROM '1.0 DIAMETER THICKNESS MATERIAL —
+1 ft. 40 ft. 6.25 ! in. #21 PVC
Company Name
„ANNNEttrA6INC ORn tlftINOVut tertnal+cl tal461 , !'iMK:',17.nl&Wef
2.Well Construction Permit#: FROM TO DIAMETER 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: ;,tt1.SG'iiEEN% ,, ` x' . s ��
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural Oi,Municipal/Public ft. ft. in.:
Geothermal(Heating/Cooling Supply) t'Residential Water Supply(single) ft. ft in.
industrial/Commercial OResidential Water Supply(shared) ,,,1'rG• oU f , ' x , ,, i w :camvrigmemlutap.
• irrigation FROa1 TO MIATERIAI. EMPLACEMENT METHOD&AIIIOUN'I'
Non-Water Supply Well: 0 ft 20 ft. Bentonite Pumped
Monitoring [Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft ft
Aquifer Recharge 0Groundwater Remediation
9 SANIVGRA;t7ELPAGi',(ifapplfcatih.YLCk At, "oramtm.:4opv
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stonnwater Drainage ft. ft.
_ Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer d 0WR1LAA11'G LOG(atR3cliTadditilitiatshoets i(Mecess'nri)W. u
FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size.etc)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) j 0 ft. 40 ft. OVER BURDEN
4.Date Well(s)Completed:9-18-2024 Well ID# 40 ft 225 ft• GRANITE _ !_
5a.Well Location: ft. ft. `,;a,,,t,,.„o ' ° :
.ft. ft. ,
ADAM VU '
{''� "..
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV t7 8, [024
606 SILVERS HOLLOW ROAD SPRUCE PINE NC 28777 ft. ft. l lr,:; -r .;, , :_. ,,.*;,
Physical Address,City,and Zip ft. ft. �'""'� r- ✓
YANCEY Eli:REMARIC.S ' ,`W .SW .., , � y
County Parcel identification No.(PiN) WFLI WAS SFI F CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
N W
9-19-2024
6.Is(are)the well(s) X Permanent or E3Temporary Sigma a of et ed ontraclor Date
By signing th arm,1 hereby certif,j that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X®INo with 15A NCAC 02C.t)100 or 1SA VCAC(I2C.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 well owner.
repair under#21 remarks section or on the back of this form, '
23.Site diagram or additional well details:
8.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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
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 if different(example-3@200'and 2@/00') construction to the following: F
10.Static water level below top of casing:45 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,«se"+" 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) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the address(es) above, also subniitl one copy of this form within 30 days of
13b.Disinfection type: 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