GW1--07721_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 YATERZONES "`_ ,c " '
FROM TO DESCRIPTION
..
Well Contractor Name ft. ft. ! 1
4614-A ft. ft. I,
NC Well Contractor Certification Number '15,,OUTER:CASING(for multi used t ells)'OR LINER(if ap`lieable) •� €'; v^'"
FROM TO DIAMETER 'THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft• 123 ft• 6.25 1. in' #21 PVC
Company Name .26 INNERCASING OR TURING(geothermal dlosed loop).
W23-0079 FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
1
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. : 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) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15::'GROUT -,: ,{r '
FROM TO MATERIAL EMPLACEMENT METIIOU&AMOUNT
❑Irrigation - 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. I Cap Top with Bentonite Chips
DMonitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation '19.,SANDIGRAV,EI]PACK(ifapplicab)e) ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM O MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft. i
❑Experimental Technology 0 Subsidence Control
20.DRILIJNG.LOG(attach i16it16nzi)sheets if necessary) ..in «.-. a-4••
"
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitirnek type,grain size etc.)
ID Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 123 ft• i' OVER BURDEN
09/28/2023 Well ID# 123 ft• 400 ft• 1• GRANITE
4.Date Well(s)Completed: ft. it.
L—- 7 1 1 ,Sa.Well Location:
ft. ft. ti,.,�,•1,.'s.�i, d�+ ii, .
JRO Investments LLC ft. ft. - NOV .2
Facility/Owner Name Facility ID#(if applicable) ft. ft. t ����
224 S Vineyard Village Dr., Old Fort, 28762 ft. ft. inc r .-,::-.!a ,-, ;.,•si Li;1
Physical Address,City,and Zip ,. '
'2E•REMARILS l :' > , A s ,' -. .* , •A.,
McDowell 066800680016 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I
(if well field,one lat/long is sufficient)
N W
• 10/04/2023
Signature of fed Well ntractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certh•that the well(s)was(were)constructed in accordance
with 15,1 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to'the well owner.
If this is a repair,fill out known well construction information and explain the nature of the I.
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
S.Number of wells constructed: construction details. You may alsoiattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.'l'otal well depth below land surface:400 (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 a 200'and 2@100) construction to the following: (
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10.Static water level below top of casing: 30 (ft.) Division of Water Resour'ces,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 ONLY:( In addition to sending the form 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
(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
5 RIG 24c.For Water Supply&injection Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this fonnIwithin 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health 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
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