GW1--02954_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 14,W+ATERZt l V;S •:w cn ge x•M
M .} ete t; '
FROM TO DESCRIPTION -
Well Contractor Name ft. ft.
4614-A ft. - ft.
NC Well Contractor Certification Number C5OILITEtt ASI.NG(fiataltt-casein elliTOR<IINER(iCaiS[ibeabtef . „^�. .- ,ti
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 55 ft. 6.25 I' ' in' #21 PVC
Company Name ,I6.:T11+tER=GAI;'INOORTUBt1IG.(kCothermPlSloYe.,4iMp) ,k„
384338-3 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. I . in.
List all applicable well permits(i.e.County State,Variance,Injection,etc.) ft. ft. ' in.
3.Well Use(check well use):
I?.SC134E XI . .. _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. r l
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply ff ft. hi.
( !� g PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) .--LS G1tOi),V..-... -___-:: .._�._: ,,!... r:
FROal TO ARTERIAL EMPI AC EME'T METHOD&AMOUNT
Dlrrigation 0 ff. 20 rt. Bentonite Pumped
Non-Water Supply Well:
DMonitoring ❑Recovery ft. R. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.:;SAND/GR:ti.ELI'iSCK faiifflicable) -....- . .- _...M-�--s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
s?2Q DRILtIb G: OO:(enact addttliinal sheets.ifueeecsar t ty,....r
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,son/rock type,grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) . 0 ft• 55 I. OVER BURDEN
2/15/24 55 ft- 205 ft- GRANITE _
f
4.Date Well(s)Completed: Well ID# d __
ft. ft. d t.,.�,kr� �,—,i`: N
5a.Well Location: ft. ft.
CMH Homes, INC ft MAY I 2024
ft.Facility/Owner Name Facility ID#(if applicable) ..^
US HWY 19/North Side Drive Lot 5 ft. ft. !r,<;i:ri,c =71 s•.�. 1...:ft. ft. is rc:�s :LV
Physical Address,City,and Zip ; M - y
Madison 9768-54 2000 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)
N W 2/16/2024
Signature of ed Well ntractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,1 hereby certify Btatthe wells)was(were)constructed in accordance
with 15A 3CAC 02C.0100 or 15A NC4C 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 til the well owner.
11-this is a repair,fill out knomm well construction information and explain the nature 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: 1 construction details. You may alsoiattach additional pages if necessary.
For multiple injection or non-water supply wells ONL F with the same construction,you can j
submit one form. SUBMITTAL INSTUCTIONS I
9.'fotal well depth below land surface: 205 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2C 100') construction to the following: ; ,
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Nlail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:I .In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) I ,
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&Injection Wells:
m I3a.Yield Method of test:
PILLS Also submit one copy of this formiwithin 30 days of completion of
13b.Disinfection type: Amount 20 well construction to the county health department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water t Resources Revised August 2013
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