GW1--07718_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells -
1.Well Contractor Information:
Taylor Ray Boger ,,14.WATERZONEs;� :: . ri _ _r .... . '..'-. ..; ;
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. O.
-
NC Well Contractor Certification Number .;IS:OUTER CASING(far ittultr eased ssvus).OR'LINER(if applicable) ' „' Ys
FROM TO DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 95 ft- 6.25 in* #21 1 PVC
Company Name ,>'16',1NNER,CAS1NG'OR TUBING(geothermal closed-loop)w :,,e,i
W23-0080 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit it: C7 ft. ft. i in.
List all applicable well permits(i.e.County,State,Variance.Injection.etc.) ft. ft. I, in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n. ft. in.;
❑lndustriallCommercial ❑Residential Water Supply(shared) tS.GROUT. ;., .
FROM 'l'O MATERIAL EMPLACEMENT METHOD B AMOIIN'I
❑Irrigation 0 ft- 20 ft* Bentonite Pumped
Non-Water Supply Well: ft. ft. i Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation '19.SAND/GRAVEL PACK(if applicable), •. _ ? '-._ -'.
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. i,
❑Aquifer Test ❑Storenwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
,-20.DRILLING:LOG(attach`additianatthhceis if necessary) :-'
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness soil/rock type.grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#2I Remarks) 0 ft' 95 ft. OVER BURDEN
09/29/2023 Well ID# 95 ft- 205 ft- GRANITE
4.Date Well(s)Completed: ft. ft.
5a.Well Location: ft. ft. _ a<''
JRO Investments, LLC ft. ft. NOV 2 2 7023
Facility/Owner Name Facility iD#(if applicable) ft. ft.
176 S Vineyard Village Dr., Old Fort, 28762 ft. ft. ",;., .,.•.-`;:;1° t;I;;i
Physical Address,City,and Zip :'21:'REMARKS=`.` .
McDowell 0666800589294
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N, t— 10/03/2023
Signature of red Well ntractor Date
6.Is(are)the well(s): OPermanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: ❑Yes or ENo copy of this record has been provided td the 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 i•
submit one form. SUBMITTAL INSTUCTIONS i
9.'l'otal well depth below land surface: 205 (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(g100) construction to the following:
t • i
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 Ceiiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6•25 (in.) 24b.For Injection Wells ONLY: II addition to sending the form to the address in
ROTARY 24a above, also submit a copy thi
s is 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) 0 Method of test: RIG 24c.For Water Supply&injectitin Wells:
1PILLS Also submit one copy of this fon-1 within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Forth GW-1 North Carolina Department of Environment and Natural Resources—Division of Water esources Revised August 2013