GW1--01159_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Taylor Ray Boger 414AYAT,,>;ZON Sr; O ii << • ni,i4 X-1,43
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. 1
NC Well Contractor Certification Number r1S GUTFR:CrtiSWG(fof mAltc cased ti ells):QR LTA ER(if apphcatilef f_.s . '
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 60 ft• 6.25 I ,in• #21 j PVC
Company Name 1`6":tiVNERi(ASINCwf)R.'ELIBING(geolierinaliclosed-lonp)) IMM=r W
398369-2 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits Be.Counry,State.Variance.Injection,etc.)
ft. ft. j in.
3.Well Use(check well use): 17:isoREEVA .. e 4.*.Mr 4 4 V ` l s T4 rK
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
[Agricultural ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) It. fL in:
[Industrial/Commercial ❑Residential Water Supply(shared) ltl GROAT ^ ° i G VO I " : w .-e "7
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 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 ❑GroundwaterRemediation 149.ISANDIGRifVgM,.,Pr\OKC(if.a»nilcaEle) .. .. N ' `'r,V gi n =
[Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. I
[Aquifer Test ❑StormwaterDrainage ft. ft. •
❑Experimental Technology ❑Subsidence Control
420:3)RIELiNGIIVatatfaehx'additiona"1 sheets ifecii .).VM-2MVINAMIM
r N
[Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(calor,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Ifeating/Cooling Return) [Other(explain under#21 Remarks) 0 ft 60 ft• OVER BURDEN
4.Date Well(s)Completed: 2-6-2024 Well ID# 60 ft. 500 ft. i GRANITE
ft. ft.
5a.Well Location: "" '` A 4—a
ft. ft. �..n �� �
BRADLEY&JANET MACGIBBENY !•"— �'''! r' D 0,,+
ft. ft. 1
Facility/Owner Name Facility iDb(if applicable) ft ft. I I't6 i 9 20 Zet,
HUCKABEE HILL ROAD MARSHALL, NC 28753
ft ft.
; , to 'gvrati D? '-,5 2,1111
Physical Address.City,and Zip 41$Rt114 ARICSx, -,,n 7 iwamorma- :,: y aor"! o.�'' '
MADISON 9735-76-3655 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/long is sufficient) ' •
N W -1--. „Lt., i ii- 2-8-2024
Signature of It— ed ell Ptractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certIfr that the well(s)was(were)constructed in accordance
with 15A NCAC.02C.0100 or ISA NCAC 02C.0200 Well Coeet,vdtion Standards and that a
7.Is this a repair to an existing well: [Wes or DJNo 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
repair under ti21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page'Ito provide additional well site details or well
S.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 t
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (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 t@t,200'and 2®100') construction to the following:
i
10.Static water level below top of casing: 1 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
6.25
11.Borehole diameter: (in.) 24b.For Infection Wells ONLY: in 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: l(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
1
(gpm) RIG 24c.For Water Supply&Injection Wells:
13a.Yield Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount 35 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