GW1--01110_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD
For Internal Use ONLY: •
This form can be used for single or multiple wells ,
I.Well Contractor Information:
Taylor Ray Boger '14AVA ,�R:ZONESI X IWZ _ATOM
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. - ft.
NC Well Contractor Certification Number WO,IkTERzCASING,(ftii•miiltt-"cis`wed"iiel s):URzi'sINER={if a)QLcatilej x, I
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 112 ft. 6.25 ; 'in• #21 PVC
Company Name #Ili:SINNER-CASfitGOR>TUBINC(gc`othermalcl'o'ied-liiiii 4,1USOXWMPt
S�/I123-0088 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V V ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): A7:iSCREEN, *W2 b,c ,: .,x, cx`: r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R ft. m.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑industrial/Comntercial ❑Residential Water Supply(shared) 18 GROIJTVII ; ,�' :101,4 .. 1n; e :O . 4 ,4� i rti
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. Cap Top with Bentonite Chips.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation NI9VSANDIGRAYZIOACIOfilititifiliiiIMAMMVIMMAIMAW MO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑ExperimentahTechnology ❑Subsidence Control
a20 fI;RT111;lISC;``UICl,(ntfiDia'ddetiariarihee sl lItie Wiii"p)3 AIN2 •20:1,:iMk
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardocss,soil/rock type,gram size,etc.)
❑Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) 0 ft• 112 ft• OVER BURDEN
4.Date Well(s)Completed: 12-4-2023 Well ID# 112 ft. 365 ft• j GRANITE T.�''+�
It. ft. �--,
5a.Well Location: Lp�-- ��E ,S
It. ft.
Jonathan Sarver&Amanda Mills ft. ft. FEB 1 c 2024
Facility/Owner Name Facility IDk(if applicable) ft. It.
•
53 Chandler Drive Old Fort, NC 28762 ft. ft. ; In`ami +rl?rn:!".:9 3IUF
Physical Address.City,and D'i�v�180C
Y• Y, P 21 REMARKS. `.40,mment men, :tt` � ` mvaa
McDowell 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(at/long is sufficient)
I
N W 12-6-2023
Signature of ed ell ntractor Date
6.Is(are)the well(s): ®Permanent or OTemporary By signing this farm,I hereby certify that the uell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction h formation and explain the nature of 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: 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: 365 (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 cr 200'and 2(100') construction to the following: l
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 fonn 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,ter,Raleigh,NC 27699-1636
(gpm) 1 RIG 24c.For Water Supply&Injection Wells:.
m 13a.Yield Method of test:
PILLS Also submit one copy of this form)Within 30 days of completion of
13b.Disinfection type: Amount: 35 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