GW1--02924_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: -. --
Taylor Ray Boger maiwmovzonsm - -.:, ,,Ipp::: - ^� if. 0 uw
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4614-A ft. ft.
NC Well Contractor Certification Number 15 AUTERs ASING(for<malts-ealed R'ells):OR L'INERAitir llcat lejs Xi -"
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 45 ft• 6.25 j in. #21 Pvc
Company Name .l'6>iNIYERCASINGORI'UBING athermsil;#tiledthiaii`) 0 4 e .M
100964 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County,State.Variance,Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): ``17$ CREEI visM M . - �. 7, z :t
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft m
ft.(Heating/Coolingf.❑Geothermal Supply) Residential Water Supply(sin le) in.,
❑TndustriaU"Commercial ❑Residential Water Supply(shared) 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 Chip:
Injection Well: ft. ft. '
❑Aquifer Recharge ❑GroundwaterRemediation ,`t9' :AND/GRAYEIv�'Pact r(ii'applleatile) M—s " ,:SUh� t!°g"
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
DAquifer Test ❑Stormwater Drainage It. ft.
❑Experimental Technology ❑Subsidence Control _
2tf.IDRiLI INGitiOD :ittaCliifddttioiL l Bheetsit"neceRakk) l MW'' -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitrock type.groin size.etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft. 45 ft- OVER BURDEN
45 ft. 205 ft•
4.Date Well(s)Completed: 2-12-2021 GRANITE Well ID# [T :,, -,-
5a.Well Location: ..�. -.1 t 1--•"9..
ft. It.
David McCourry ft. ft. MAY [024
Facility/Owner Name Facility ID#(if applicable) ft ft.
Guilders Creek Road Burnsville, NC 28714 ^°r a 1.1 x
ft ft. ll "�
Physical Address.City,and Zip "i21 RENIARKSM :. M ' MI' .ux*`:?..`M10 V,A
Yancey 082200006427000 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient) ,
N w 2-15-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary .
By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance
with 15A NCAC.02C.0100 or I5A NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or 0No copy of this record has been provided to'the well owner.
If this is a repair,fill out knonsi 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
S.Number of wells constructed: 1 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. SUBMITTAL INSTUCTIONS i
9.Total 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@@100`) construction to the following:
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10.Static water level below top of casing:60 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:j 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:
(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
I3a.Yield(gpm) Method of test. RIG 24c.For Water Supply&Injection Wells:
8PILLS Also submit one copy of this form; 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013