GW1--06739_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Kolby Mitchel Sawyers 14.;wATz RrxoN s.. . will-i .....A. 4 i t: w . `r'
Well Contractor Name FROM TO DESCRIPTION
ft. ft. 1 1
4471-A
ft. ft. 1
NC Well Contractor Certification Number :•15:OITITR CASING"(fer nCutit eased Whlis)-ORLINER:(if`)4ippl1leable)�°` W x •;a s
CLYDE SAWYERS &SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft• 57 ft• 6.25 1 in• #21 PVC
Company Name
EH 24137 46.1.NNEWGASING ORTLrB NOO.o iernrai`closed loop) .
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: 17.SCREEN. °,! ., _ .,{_�k >., 'I ," _. -, , .,
FROM TO DIAMETER SLOT SIZE THICKNESS f MATERIAL
Agricultural D Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. inl:
Ru Industrial/Commercial ()Residential Water Supply(shared) is.GRou m, _ ; . ' ,,,,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pumped
.*IMonitoring DRecovery ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
!Aquifer Recharge 0 Groundwater Remediation I
IAquiferStorageandRecovery SalinityBarrier "'i9i'SANU1GR :XVEL'PACK(Ifaiilirabtf} ., -$: ?.a;d 3'°,-, r., „",°f',
FROM TO MATERIAL EMPLACEMENT METHOD
Ai Test 0IStormwater Drainage ft. ft.
X Experimental Technology ®Subsidence Control ft. ft.
*Geothermal(Closed Loop) DTracer ',"20.DRII;TJI'TG;EOG(attach additioaalasbtetsaf riect'?ila
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks)
0 ft 57 ft. OVER BURDEN
4.Date Well(s)Completed: 10-23-2024 Well ID# 57 ft.
t 325 ft• GRANITE
5a.Well Location: ft. ' ft. kn .,'�
BEATRICE MERCEDES ESQUENAZI ft. ft. 6 t s...,,-`k,.,,+ m h f;�-.4 .�
ft. ft.
Facility/Owner Name Facility ID#(if applicable) d
NOV y
BLESSED VALLEY RD/MILL SPRING . NC ft. ft. 1, 2 L02
Physical Address,City,and Zip ft. ft f �: :7,-,-----'-�,R 4., !,y,r'
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POLK P80-41 "s21.REMARI(S)x, .„,1. v -lam ,w •;=.
County Parcel Identification No.(PIN) THIS W F I I IS S F I PI-GROUT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certification: I
N W 10/31/2024
6.Is(are)the well(s) i Permanent or Temporary Signa e of Ce edontractor Date •
Br signing th form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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#2I 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS<
9.Total well depth below land surface: 325 (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: I
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10.Static water level below top of casing:20 (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: 6.25 (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.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Clenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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: 25 completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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