GW1--07542_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
I.Well Contractor Information:
Taylor Ray Boger ' ZIUWAT IVZONES • — ==VOW� >4 :
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I
4614-A ft. ft. a
NC Well Contractor Certification Number 15 OUTER G ISING'(forrmulft c°Sstd'tseBs)7}R[L1ER'(tt by Iicatil"e) � �
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft 64 ft• 6.25 in. #21 Pvc
Company Name
1`t;iNNER CASIhG:OR+sTUBiNG`(Reotltetmalfctrissdlfuap;�" " � ' ``
OSS-2023-1184 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ise/I permits(i.e.Coung;State.Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 1.7 SGitEENi s. ,004 >� -. x 4. P§
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) FiResidential Water Supply(single) ft. tL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 418 tlitl T "
FROM TO 5 MATERIAL' EMPLACEMENT METHOD&AMOtUNT
olrrigation 0 ft. 20 ft' Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I9,SAiVL11GRAV,I 4P'r1t3IC(iC.ippBGable) 5 4 -. . i:—I '
['Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fr. ft. I
0 Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
a 20aDRiLL1NI I OG lathe!3ddttigrial'shWiEnececsfirp) . , .> . -
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 • ft. 64 ft. i OVER BURDEN
9-18-2023 64 ft. 225 ft. i GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. IR
AGNES QUERENS ADAMS k."y "^�' U`'•- '
ft. ft. 1/ �}
Facility/Owner Name Facility Mg(if applicable) ft. ft. NO V 2 1 2023
0 GREEN RIVER SUBDIVISION ZIRCONIA ft. ft. ' Ifi;3,,;:..V!..:n C.3.7. 1 U,:i
Physical Address,City,and Zip i 2114tEl1fARKSWe , eft. ' '
HENDERSON 9555896016 WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/Iong is sufficient)
9-19-2023
N W Signature of led ellctor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to thi well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.you can
submit one form. n SUBMI'I"I'ALINSTUCTIONS I
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2®100) construction to the following:
1: ,
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If Hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For injection Wells ONLY: .in addition to sending the fonn to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY . 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) 12 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013