GW1--03504_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD • For internal Use ON
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONE:,
FROM _tO DESCRIPTION --Well Contractor Name ft. ft. --
4614-A tt. ft.
NC Well Contractor Certification Number I .OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER TIII(-KNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 66 ft• 6.25 in. #21 PVC
Company Name 16.INNER C'ASING.OR TUBING(geothermal closed-loop)
010124-1 FROM TO DIAMETER Tlllt hNESS MATFRIA!
2.Well Construction Permit#: ft. ft. in.
List all applicable yell permits(i.e.County,State, Variance,hyection.etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MIATERIAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial [Residential Water Supply(shared) It(.Gttot'T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Kecovery ft. It. Cap Top with Bentonite Chips
injection Well: ft. II.
❑Aquifer Recharge ❑Groundwater Remediation ASAND/GRAVEI.PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) : V;
❑Geothermal(Closed Loop) ❑Tracer FROM I O DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) 0 ft• 66 ft. OVER BURDEN
411 2024 66 ft- 505 GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
JAKE WATERS ft. - I:EC�.:!vED
Facility/Owner Name Facility lL)# if applicable) . ft.
JUN 1 2 ZR24
1234 BROOKS LANE OTTO, NC 28763 ft JUN
Physical Address.City,and Zip 21.REMARKS irdl..—nem:: f'-r-rtso%:,•2 Ups•
MACON 6489774814 1,1i(N'�,-;
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W, 5-2-2024
Sigtwture of led ell ' ntracWr,1Lae Date
6.Is(are)the well(s): 2Permanent or OTemporary signing this orm.I herebycerti that the xell(s was(were)constructed in accordance
B3'.'get 8 .� fY )
with I SA 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 ElNo 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#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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-issuer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (if,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(02200'and 24100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+-- 1617 Mail Service Center,Raleigh,NC 27699-1617
t t.Borehole diameter: 6.25 (in.) 24b. For Injection 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY%\Ia.LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Ale thoil of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
___—__ ___ Amount. 35 well construction to the county health department of the county where
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013