GW1--06637_Well Construction - GW1_20241108

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WELL COjlrSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Kolby Mitchel Sawyers ,z4 vaa , s; �:.w e r .c 5t, <.N =,3'..< t.3_., ,
Well Contractor Name FROM TO DESCRIPTION
4471-A ft. ft.
ft. ft.
NC Well Contractor Certification Number
" s otrrmc,sli c.(fnt;iriuln c0,6a yells)`©R.r'rvERtlt'.a smile) z: ,
CLYDE SAWYERS &SON WELL& PUMP INC FROM ' TO DIAMETER THICKNESS MATERIAL
+1 ft. 40 ft- 6.25 1 in, #21 PVC
Company Name
0� CJ2 16;INNERtaBINOGRIORINGrWiit erttiiilcldscd . ;leifP ,P
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: - 1.05CRihEN ,' w� 7".,x J, ,>0' §. <
FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
Agricultural OMunicipal/Public ft. ft. ins'
'*Geothermal(Heating/Cooling Supply) EE1Residential Water Supply(single) ft, ft. in:
Illit OResidential Water Supply(shared) ,fn (1 TT11�[
10.Gi2v,1+,A'0..0.g.^ 1,d&%•i6,lAr1,I: b ,� 3:.,i , *.... Sr=.. zJ:..
!I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
I Monitoring E3 Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: t't. ft.
(Aquifer Recharge 0Groundwater Remediation
z'1<19 SAND/fRAVUTACt tirUpp"Ittalite), < . 4 .`
(Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
**Aquifer Test DStarmwater Drainage ft. ft. .
111 Experimental Technology 0Subsidence Control ft. ft.
*(Geothermal(Closed Loop) OTracer 20;1)RICCINGeGOG.(affaib`;<dditao"tialslreets.tfriec ssar3) `:,"i:
*Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
p ft. 40 ft. OVER BURDEN
4.Date Well(s)Completed:09-23-24 Well ID# 40 ft toy ft GRANITE
ft. ft.
5a.Well Location:
Kenneth Clark ft. ft.
, �.
,. .: % "27.d..,.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Silvers Gap Rd ft. rt. i. NOV 0 8 2024
Physical Address,City,and Zip ft. ft.
�� Rimy 080100366289000 2i:°3tEMARE ` ,.. ..Wifi,,ai._43,AF,W,W:-,, ... •ft ,_ 1,-;7?";
County UayJt Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N v 7' 09/23/24
6.Is(are)the well(s) Permanent orETemporary Sigrra a of Ce ed • ontractor Dale
8y signing fit form,I hereby certtj that the well(s)was(were)conshrrcted in accordance
7.is this a repair to an existing well: EjIYes or ENo with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction MO-motion and explain the nature of the copy of this record has been provided to the trell owner.
repair under#21 remarks.section or on the back of this form. '
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this;'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2 a 100) construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resou I'rccs,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 thi' form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C snter,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 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: 15 completion of well construction tot the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
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