GW1--07719_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
. This form can be used for single or multiple wells i'
1.Well Contractor Information:
Taylor Ray Boger 14PWATERZONES ,4-< a °g r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number ',AS':OUTER_CA#l,tN(s or mu,ti4 asvd.wetls)OR'LINER(it*plikdble)?• : , . F!.k'i
_FROM TO DIAMETER THICKNESS MATERIAL CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 95 ft• 6.25 : in• #21 [ PVC___
Company Name 16.INNER CASING OR TUBING(geothermal'-closed-loop)" a
W23-0080 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.Stale.Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER , SLOT SIZE THICKNESS , MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. m
❑industrial/Commercial ❑Residential Water Supply(shared) AR.GROUT. -
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ['Recovery '
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK(If applicable)..:`o-`, , ' .„-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control -20.DRILLING LOG(attach additional_sheets if necessary) ., ,, .
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. ' OVER BURDEN
09/29/2023 95 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Well Location: I i l `Sa.
JRO Investments, LLC ft. ft. t{. n.F7�.,,r,; V�R^`;
ft. ft. «O L1/
Facility/OsvnerName Facility lD#(if applicable) ft. ft. • !' 2 2023
176 S Vineyard Village Dr., Old Fort, 28762 ft. ft. In c;7:':.'-1; ::-)•:- US .i
Physical Address,City,and Zip -211 REMARKS. :!, , L,., .'t s„`4' , '*
McDowell 06668005'89294 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 lat/long is sufficient)
r- i
10/03/2023
N w Psi
Signature of t red Well .ntractor ; Date
6.Is(are)the well(s): RPermanent or OTemporary
By signing this form,I hereby certifi,that the well(s)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 ENo 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 stature of the i
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: construction details. You may alsoattach 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: 205 (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@l00)l00) construction to the following: i
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Celiter,Raleigh,NC 27699-1617
I
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 form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Colter,ter,Raleigh,NC 27699-1636
24c.For Water Supply&Inject[In Wells:
13a.Yield(gpm) 1 0 Method of test: RIG
PILLS Also submit one copy of this foim'within 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
I
I