GW1--04718_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal use ON l'
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger ..14.WATERZONES
FROM TO DEM-HIFI ION
Weil Conu...,.'I Rams. ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number I5 OUTER CASING(for multi cased wells)OR LINER(if applicable)
t ROM 10 1)1.'Sit 11 It M u It I 11111 1,\ \S . 1.R1M ~
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 87 1t• 6.25 in. I #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-Loop) -__ _ 1
S OS-2024-0033 FROM ICI DIAMETER _ TInCKNESS St11I1410
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance.Injection,etc.) FE ft in.
3.Well Use(check well use): ---
17.SCREEN
Water Supply Well: FROM TO 'DAME IER SLOT SIZE 1'Ill('E\ESS MATERIAI.
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. In.
( 8/ B Pp Y) PP
❑Industrial/Commercial ❑Residential Water Supply(shared) ltV. U T
FHUMt GRO TO ti%ILIUM., EMPLACEMENT METHOD&AMOUNT'
❑Irrigation 0 fa it
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite ChipE
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if�ble) _
tRI1A1 1(1 M A IFRIAl, l'VWI 1(F:AIFN I SIF-11ll))
❑Aquifer Storage and Recovery ❑Salinity Barrier tr. n
❑Aquifer Test ❑Stormwater Drainage
-
ft. ft. 1
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardncse.son Frock type.grain size.etc.) j
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 87 It. OVER BURDEN
07-10-2024Well ID# 87 rt. 705 ft. GI�AN1TE - _ _
4.Date Well(s)Completed: It. ft. ....�,.r ' :-
s.Sa.Well Location: tl.•• l._. i
R. R.
HOMES OF CLAYTON/CMH ft. ft. ----- AUG 1 2 2024
Facility/Owner Name Facility ID#(if applicable) ft. R. u
73 WHISPER MTN RD — If"°'i:7..`7� . ..-d I..ir.31
ft. ft. DI.C.. 1rti
Physical Address,City.and Zip
It.REMARKS ' a=`
HENDERSON 0611761308 -
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 1. % 08-01-2024
Signature of lied Well ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form.I hereby certiJ'that the walls)was(were)constructed in accordance
with 15A feCAC t02C.0l00 or I5A 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,ill out known well construction information and esp/alit the nature oj'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-water supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:705 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-364200'and 1@100) construction to the following:
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 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy ot'this form within 30 days of completion of
13b.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
Form G W-t North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013