GW1--05626_Well Construction - GW1_20240916

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonm can be used for single or multiple wells
I'
1.Well Contractor Information:
Taylor Ray Boger 014...W 1 4ATEflZON # f ,fi . . ':4,h:iY" z
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number SSrf1UTER ikSING(foii:riiultr-cared'>;ells)>U1tIiINER{tf iNj)LcalitgEMI.s. ,s xis":
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 94 ft. 6.25 1; in. #21 PVC
Company Name r 1(i.tNIVGR'CASINGI,Oftiff113ING,(gcofhermiil.closMl-tonp)tr '. ; is .. n.„.W
050524-1 FROMTODIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I. in.
List all applicable well permits(i.e.County,State.Variance,Injection,etc.) ft. ft. 9 in.
3.Well Use(cheer(well use): 1.7:iMtEEN «' «.�:W - -t ` a x:x.N.. :W` W 4 ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. , ft in
❑Geothermal(Ncating/Cooline Supply) ❑Residential Water Supply(single) ft. ft. in...
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM
:GROLIT : M " ' "IcP ErnM - O &
_ AMOUNT
❑irrigation 0 ft, 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation makmititostenkociiimieitifeRnwftimzkammtwovxmm
FROM TO MATERLtL EMPLACEMENT METHOD
[Aquifer Storage and Recovery ❑Salinity Battier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control
P401,IDRIEEIBO%0MaltilibasiditialialWaslrifilWOMitienr4MWR
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Beating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 94 ft. OVER BURDEN
4.Date Well(s)Completed: 8-6-2024-Well 110 94 - ft. 405 ft. GRANITE
ft. ft.
5a.Well Location: ft. ft.
CODY BOWLING ft. ft. .
Facility/Owner Name Facility 1Db(if applicable) ft. ft.
SAUNDERS ROAD FRANKLIN, NC 28734
ft. ft. ,
Physical Address,City,and Zip :21 tun4i1RKS, VT, v.✓: .:r 44?ura H?vixaS,Mz3 .yr= ^';
MACON 7504294076 THIS WELL WAS SELF CERTIFIED
County Parcel identification No.(PiN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification •
(ifwell field,one lot/long is sufficient) '
N W 8-12-2024
Signature of ied ell ntractor : Date
6.Is(are)the well(s): RlPermanent or ❑Temporary By signing this form,l hereby certify that the iiell(s)was(were)co, rc7ed•itt d.faQce�rr`�,
with 15.4 NCAC 02C.0100 or 13.1 NCAC.02C.0200 Well Constructibftri' einnabids,ir{Sl iirrtt a t�j!
7.Is this a repair to art existing well: ❑Yes or DNo copy of this record has been provided to the well owner.
lf this is a repair,fill out known well construction information and explain the nature of the c p t 2074
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details: ,j E r 1 b L
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 a rg!,_,, ;Dtf:-c*tt>+;:?j U
For multiple injection or non-water supple wells ONLY with the same construction,you can OW CiY' '°a
submit one form. SUBMITTAL INS'li'UCTIONS , '
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@u,200'mid 4000') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If ater level is above casing,use'-4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 6.25 (in.) 246.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 WELLS ONLY: 1636 Mail Service t etinter,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS 35 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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 WaterResources Revised August 2013