GW1--07667_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY: i -
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger tf4:W TElt 0SES :s FM E ;
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1 1
4614-A ft. ft.
tIS4.tITERW-SING.(ToaififffP ise`tl elfa)DII',I.INl t3(at''`t lieib .:
NC Well Contractor Certification Number FROM _ TO DiAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 21 ft. 6.25 j, ; in. #21 Pvc
Company Name :,tri;Ic51s'+talirASl1 :O1r.UBtNOtReixlaertgitic(p'se;t-l+G9i)S ..--.-s ' -.-f-
100854 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i . in.
List all applicable well permits(i.e.County,State.Variance.injection,etc.) ft ft. in*i
3.Well Use(check well use): 17 GREi•IW . : . .,, z ..RW�...A- . k <'" „ -5. t,tY ,,..:t:
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS - MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft f r in
❑industriallCommercial ❑Residential Water Supply(shared) -I 'OitOUT` �' �'�'_ -' `'' tia? x_ '� . .7e ---- a..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOIlhT
°irrigation 0 ft. 20 ft. Benttnite Pumped
Non-Water Supply Well:
ft. ft. j ' Cap Top with Bentonite Chi
❑Monitoring ❑Recovery p,Injection Well: ft. ft. i ,
❑Aquifer Recharge • ❑GroundwaterRemediation 19.S NDIGRh3 t rAM.riViiiiillitibleVEMMUMMUMMMUMM
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft• ft. i,
❑Aquifer Test ❑Stormwater Drainage ;
ft. ft.
❑Experimental Technology ❑Subsidence Control 40AHIIL'tit MOG iiiietiaddttinifa eetsafaeccssadMVMW ` >,-.,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 21 ft- OVER BURDEN
10/24/2023 • 21 ft. 485 ft. GRANITE •
4.Date Well(s)Completed: Well ID# ft. ft. _
i ,_
5a.Well Location: ft. fa I _, `' ,i/' '- i
-''�-:-,a .,., ,.,.
Joshua Cole fr. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. rJ O 1/ 9 J `n 99
23
Lot 9, Chasing Dreams Dr. ': ; , .-
ft. ft. �r.;.. �,: . '� i jr2a.
Physical Address,City,and Zip �IZRE ARKS ...-.,. z .`..-fir'.'- - .._"M .
Yancey . 0801007048590 This well was self certified
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i 22.Certification:
(if well field,one tat/long is sufficient) 1
N � e i 10/27/2023
Sign d We�toI Date
6.Is(are)the wells: PI Permanent or OTemporaryi
O P By signing this form,I hereby certify,drat the well(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC.4C 0?C.0200 nu Construction Standards and that a
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7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
If this is a repair,fill out know,well construction information and explain the nature of the
repair under 421 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. o SUBMITTAL INSTUCTIONS h
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3E4200•and 2@100) construction to the following: '
80 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft) Division
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 ONLY{: iIn addition to sending the fonn to the address in
ROTARY 24a above, also.submit a 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
t
20 RIG 24c.For Water Supply&Injection Wells:
I3a.Yield(gam) Method of test:
Also submit one copy of this fnrm within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county stealth department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013