GW1--02952_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 614:W ERZON:s : , _ 1
FROM TO DESCRIPTION
%Yell Contractor Name ft. ft. ! 1
4614-A ft. ft. . 1
NC Well Contractor Certification Number 1SIOUTER CASINC.(far itiiiltilease l 'ells)`OR LINER4ifsrtpplieablej '','
FROM TO DIAMETER. THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 90 ft 6.25 ! in. #21 PVC
Company Name `1frAINNER:�Cr\SIN'G:OftiTUBING(geofhiiiiin':closedrltiuji); i. ,;1X
839694 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ; in.
Lit all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use): '7;SCR1tEN,::, ,4 a ?4 ?M !'" -' k*WOK.+M
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. _ ft. in;,
,
❑Geothermal(Heating/Cooling Supply) eIResidential Water Supply(single) h ft. in1
❑industrial/Commercial ❑Residential Water Supply(shared) t.1l3 R41i1Tw � �' �� e J Ah .
FROM TO MATERIAL EMPL4CEMENI METHOD 3c AMOUNT
❑Irrigation 0 ft• 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
:Aquifer Recharge ❑Groundwater Remediation .1149 SAND/GRAVE Pe1('IC'(if apjilfetiblel. '''W SA,,
FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage .
ft. ft. I.
:Experimental Technology ❑Subsidence Control
2U DRiLLING 1.OMaallachaddttiionlii sheetiittiececs i ; M
❑Geothermal(Closed Loop) ❑Tracer _FROM TO DESCRIPTION(color,hardness,soiurock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 90 ft. OVER BURDEN
90 ft. 285 ft. GRANITE
4.Date Well(s)Completed: 2-13-2024 Well ID# r
ft. ft. =.. :. .
5a,Well Location: ft. ft. "
TEREVA HUGHES ft ft. MAY 1 2024
Facility/Owner Name Facility ID#(if applicable) ft, ft. ! IT`.:rz-:n.Z+;.n 7)--r• .,. ••_l 1.,^i
1014 HANGING ROCK ROAD SPRUCE PINE, NC it. ft. ''+'eiw' O;;
Physical Address,City,and Zip 2111RF.111ARt{S :.r • • '�. _ ,' '. MNII:VI'
MITCHELL 180200504359 WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(it'well field,one Iat/long is sufficient)
N W ` 2-15-2024
Signature of ed ell ntractor I Date
G.Is(are)the well(s): ©Permanent or ❑'Cemporary 13y signing this form,I hereby certify that the twills)was(were)constructed in accordance
with 154 NCAC 02C.0100 or 15,4 NCAC.02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ENo copy of this record has been provided to,the well owner.
I/this is a repair,fill out knos'well construction information and explain the nature of the I
repair under 121 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 alsolattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the smite construction,you can
submit one form. SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(caample-3@200'and 2 t®r 100') construction to the following: I,
10.Static water level below top of casing: 30 (ft.) Division of Water Res urces,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,Raleigh,NC 27699-1636
(gpm) 20 RIG 24c.For Water Supply Sc.Injectio"n 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: 30 well construction to the county health department of the county where
constructed.
li
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013