GW1--03512_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES _I FROM TO DESCRIPTIONI
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(fur mu�sedwells)OR LINER(Hap licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 68 ft- 6.25 in• #21 PVC
Company Name 16,INNER(AASNG OR TUBING(geothermal closed-loop)
2022-22792-9-11883 FROM TODIAMETER Ia• THICKNESS MAT ERIAL
2.Well Construction Permit#: ft.
list all applicable well permits(i.e.County,State.Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: ERoM 'to Ii1:\MET ER SILLS SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipallPublic _
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single)
❑industrial%Commercial ❑Residential Water Supply(shared) IB•GROUT
FROM TO MATERIAL EMPI.ACEME:N1 Nit.SHOD&.SMOIINT
❑Irrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑RetxEvery I ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
•
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL E�IPI Ale�1r VI METHOD
ft. ft.
❑AquiferTest ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.)
CJGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 68 ft. OVER BURDEN
4-18-2024 68 ft- 165 ft• GRANITE
4,Date VVell(s)Completed: --Well ID#
ft. ft.
5a.Well Location: ft. rt.
JASON A BURKE
ft. ft. 4-tC.P s VEL)
Facility.Owner Name Facility!Dk(if applicable) ft. ft.
ALLEN HENSON CIRCLE SYLVA, NC ft. ft. JUN 1 ? 7024
I'hssisal Address,City,and Zip 21.REMARKS -- ,
JACKSON 7642-33-7068 --
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 �n 0. 4-18-2024
Signature of fed ell ntractor Date
6.Is(are)the well(s): lid Permanent or ❑Temporary
8y signing this form.I hereby certify that the utell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or LINO copy of this record has been provided to the welt owner.
/jthis is a repair,fill out known well construction information and explain the nature of the
repair under 421 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200•and 2@l00') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,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 Injection Wells ONLY: In addition to sending the fonts 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:
ti 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
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: 20 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