GW1--06701_Well Construction - GW1_20241108

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IInt form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14 AvAl xttioiicza ''Ueu,,*.ixrdfotax � ,.A `N -9:
Well Contractor Name FROM TO DESCRIPTION
4471-A ft. ft,
ft. ft.
NC Well Contractor Certification Number l'5;.O1l I:ER GOAS IY(r.(far fiiitti-cased fells}tiltIANEIi'(if'eprlicatil`ej *M
CLYDE SAWYERS & SON WELL & PUMP INC FROM co DIAMN lERi 'THICKNESS MATERIAL
+1 ft• 132 ft 6.25 'in. #21 PVC
Company Nome ,,... . �,�
WEL2023-00002 451I{VIPER-CASiN04,W'1`1J13lM1dfaaa her dat`clgsed tooiiinga: gk : ;
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.
W ater Supply Well:Agricultural ['Municipal/Public 1 ^I SCR �,xREN zW W-„ V , c M vg
gin
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)Industrial/Commercial
irrigation
Non-Water Supply Well:
ft. ft. in.
Residential Water Supply(shared) tSGROUT3 � x �
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
0 ft. 20 ft Bentonite Pumped
Monitoring
Injection Well:
�Recovety ft. ft. Cap Top with Bentomite chips
ft. ft.
Aquifer Recharge Groundwater Remediation
�I4�SA7tili/G'Ri'Ll?EL�1".S131G'(f ir`RPlirahle}1�,����„m��'t,
Aquifer Storage and Recovery Salinity Barrier FROMTO MATERIALEMPLACEMENT METHOD
Aquifer Test 13 Stonnwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .ZO ARIl.LING I Oftti actiiaddlttotiat'sheetsxfneces"saiv)'1,% ..'
FROM TO _ DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 132 ft• OVER BURDEN
4.Date Well(s)Completed: 10-8-2024 Well ID# 132 ft. 225 ft• GRANITE
Sa.Well Location: ft. ft. t' " ---y
Li
JOEL WIENS ft. ft. t' f'` ." ;f - t
Facility/Owner Name Facility ID#(if applicable) ft. ft. . �VIIU 8 2024
;t;
14 WILLS LANE CANDLER, NC 28715 ft. ft. ;;:;r;,i i r ,i:
•� ,.,
Physical Address,City,and Zip f[. ft. D:`v ti,u' 0-.3
BUNCOME 96085095470000 21.1i> EklucS am 3:ZV '
County Parcel Identification No.(PIN) WFI I WAS SFLF CFRTIFIFl)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lot/long is sufficient) 22.Certification:
N W 10-17-2024
6.1s(are)the well(s) X Permanent or Temporary By si;ingthSigna a of
C er ed onttactor Date
By signing th Jbrrn.1 hereby certifj•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or % No with 15,4 NCAC 02C.0100 or 15A NCAC,02C'.1)21)0 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:
S.For GeoprobefDPT 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-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: 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 .100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.2rJ (in.) 24b. For Infection 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.) i
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&IniecNbn 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016