GW1--02953_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD For Internal Use ONLY: P ,
This form can be used for single or multiple wells
• 1.Well Contractor Information:
Taylor Ray Boger l4 W FFRZONEs.,. VOILA ., M UAl.. Alitft51
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I
chle 1540ITT ER=CASIi4 O far:tu lltl Aii18 ells);OltI INtfe if a i hi ,k , .
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 39 fit• 6.25 , in• #21 PVC _
Company Name 16.111 NER CASINGVIt?TURIN ()wenthkrniisil'ctasetwirtii"...
384334-3 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(Le.County,State,Variance.Injection,etc.) ft. it. in.
3.Well Use(check well use): SiiREIrN - , V .,04 ,.h
Water Supply Well: FROM To DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in-
['Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k fit. in:
❑industrial/Commercial ❑Residential Water Supply(shared) 8G1Y117f " °
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fit• 20 fit• Bentonite Pumped
Non-Water Supply Well:
"Monitoring ❑Recovery ft. ft. 1; Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 1.9 SAN11/_GUI;A;Y,Et,,P1t&(tfapplt<x m.I/, ; 7 ' CtE"
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft, fit.
['Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ['Subsidence Control
20',11TtIt% .BOW(atiaclt''acldttilineil'sheetstif:necessnrp) `` 'M, ..
['Geothermal(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. 9 ft. OVER BURDEN
2-14-2024 39 ft• 165 fit fRAbIIZ _ _
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: h. ft MAYE�2`t CMH HOMES INC ft. ft.
Facility/Owner Name Facility 1Db(if applicable it. ft. ( ITrvib,,fi r.n, r'''^s' -.,',.<- !.
" =y JIt
NORTH SIDE ESTATES LOT 3 MARS HILL, NC ft. fit. . . cr ;:a"st
Physical Address,City,and Zip 1 REM'OXISs 9 g _ , `rw . .
MADISON 9768-54-2000 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 Iat/long is sufficient) `
N W , 'E er 2-15-2024
Signature of I. - ed ell ntractor I Date
6.Is(are)the well(s): ElPermanent or ❑Temporary signing this onn,I herebysera that the uell(s was(were)constructed in accordance
By g g f h ,. I
with 15.4 NCAC 02C.0100 or 15.4 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 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: 1 construction details. You may alsoiattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the scone construction.you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: i 65 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3i7)200=attd 2 cu100`) construction to the following:
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10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-t-•" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 ofi,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 Center,Raleigh,NC 27699-1636
(gpm) RIG 24c.For Water Supply&Injection Wells:
13a.Yield m 12 Method of test:
PILLS Also submit one copy of this fain within 30 days of completion of
136.Disinfection type: Amount: 20 well construction to the county healh department of the county where
constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water f esources Revised August 2013
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