GW1--04700_Well Construction - GW1_20240812

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
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. rt.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 70 ft• 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBfNG(geothermal closed-loop)
JMQ-334W FROM TO DIAMETER THICKNESS MAT t:RIAt.
2.Well Construction Permit#: ft. ft. in•
List all applicable well permits(i.e.County,State.Variance.Injection,etc.) h. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DI%ME:"I ER SLOT SIZE THICKNESS _ M:1rE,Rv L .
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft, ft. in.
(Heating/Cooling Supply) OResidential Water Supply(sin Ie)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO _ MAT E:RIAI. EMPLACEMENT ME I HOD.Y AMOUNT
❑Irrigation 0 ft20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applictibit),
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. •
0 Experimental Technology ❑Subsidence Control '
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM 10 DESCRII'TION'(color.hnrduess.soil/rnck i.pe.grain sire.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 70 ft. . OVER BURDEN
06-20-24 70 ft• 405 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. -
Hams,Gregory Daniel Harris,Laura Louise +�.\ f l"'
ft. ft.
Facility/Owner Name Facility ID*(if applicable) ft. ft. '+'U G 1 20
122 Pipers PL., Clyde ft. ft. _
Physical Address.City,and Zip 21.REMARKS
Haywood 8648-6-2-4582 THIS 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 IatAong is sufficient)
N W _ 06-28-2024
Signature of ed Well t ntractor Date
6.Is(are)the well(s): fra Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A 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 EINo 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 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.par eon
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 at.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di-(jerent(example-3ta)200'and 2C 100') construction to the following:
10.Static water level below top of casing: 50 (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 form to the address in
ROTARY 24a above, also submit a copy of this fool' 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
13a.Yield(gpm) 15 Method 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: 15 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