GW1--05621_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells
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1.Well Contractor Information:
Taylor Ray Boger :4 �� T, n t>NFS :. .� �,. w.-Wi N Vi. .
FROM TO DESCRIPTION,'
Well Contractor Name ft. ft.
4614-A ft. ft. I 1
NC Well Contractor Certification Number ..if.WOFFERVASING4fobiiiiltiiialiiiiiMEOGRITNEftillfailieable)VAIMMWt
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 ft. 6.25 ;`i°• #21 PVC
Company Name ,`16izlNNC12:CASIP'firt3RTIIBINf',(eeoihermliliclosed-lo"oF) r ' -r? < ` >,
OS
S�202A-0118 FROMf0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i ft. ft. ; in.
List all applicable well permits(i.e.County,Store,1•iu•iance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use): 111SCREEN AIMM 1 r 5 ti`'�Fi -
Water Supply Well: • _FROM To , DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. :n.
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R• ft. In.
DGeothermal Heating/Coolin Supply) OResidential Water Supply(single) ' - •
❑industrial/Commercial ❑Residential Water Supply(shared)' ltV.GRUUT M'`�'Ws. c ".. , t t t. , ,,, .,-
FROM TO MA ERL\L ' EMPLACEMENT METHOD'.4:'AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND`/GR?CIL PrC('K`(ff:npoicatill`e), ee' l ,s.'' ; _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. ,
❑Aquifer Test ❑Stormwater Drainage -
ft. ft. '
❑)xperimental Technology ❑SubsidenceContro] fl DRiLLiNGLOGlittacti-additional`sheets'if:uececsln)MP M,
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soiVrock type.grain size.etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 56 ft. OVER BURDEN
7-18-2024 56 ft. 185 fr. j, GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
STACY LYNN OWEN ft. ft.
Facility/Owner Name Facility iDI((if applicable) ft. ft.
3791 OLD US HWY 25 ZIRCONIA, NC ft. ft.
Physical Address,City,and Zip 421 RIsh2Al2KS; §;A ,A n .MZWal '3. NeIAV s
• HENDERSON 9574447/26 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one lat/long is sufficient)
N W 07-20-2024
Signature of led ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 8y signing this form,I hereby certify that the well(s)was(wen of#Trlic76 ,Fdc J, (r d
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cact rtli�i r'$}tr�rt�atd..adVaict 0
7.is this a repair to an existing well: ❑Yes or El No copy of this record has been provided to the'w+ell owner.
If this is a repair,fill out known well construction h formation and explain the nature of the C[p u 909 A
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details: J`I L L`t
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 pi.:e,grlirgisssltrl?rr t7;t,;;;;ys IJ
For multiple injection or non-water supply wells ONLY with the same construction,you can DIN;;Ss.;,(j y
submit one form. O c SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: 1 85 (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: 30 (ft.) Division of Water Resources,information Processing Unit,
inter level it above casing,use"+" 1617 Mail Service Center,er,Raleigh,NC 27699-1617
Il.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.
(i.e.auger,rotary,cable,direct push,etc.) ; 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center),Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form vi?hin 30 days of completion of
13b.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
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