GW1--02955_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD For Internal Use ONLY: _!
This form can be used for single or multiple wells •
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1.Well Contractor Information: '
s 14;v.@ATE1t.7ONES.. .
Taylor Ray BogerRI.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ' ft. '
NC Well Contractor Certification Number -ISifOIITER:CiASING(for>multi-cateiFii lls):ORLiNER(ifap Ucablej
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 44 ft. 6.25 ; in. #21 PVC
Company Name 16::INNER,GASIivG ORIIIIII 1("irTgeetherrtiatiosedaigiti
384337-2 FROM TO DIAMETER THICKNESS p MATERIAL
2.Well Construction Permit#: ft. ft. I in
List all applicable will permits(i.e.County,Stale,Variance,Injection,etc.) -
ft. ft. j, in.
3.Well Use(check well use):
.:k7.�SGREF`Nn:���. : . �. a ,
Water Supply Well: _FROM - _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) elResidential Water Supply(single) R. ft. in.
❑industriaLiCommercial ❑Residential Water Supply(shared) 18.GROUT..
FROM TO MATERIAL EMPLACEMENT ACEMENT METHOD&amomi r
❑Irrigation 0 ft, 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:SANDIGR,Al?ELL,P.AGK(ifappheable)
FROM TO MATERIAL EMPLACEMENTMETHIOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
:2kiDltiLIING ti[1G(attoekfidditii na7 shcnta f ncceis'itt-, -:: ,.;
❑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 44 ft. OVER BURDEN
2/14/24 44 ft. 225 ft. GRANITE
4.Date Well(s)Completed: Well ID# ----
ft. ft.
5a.Well Location: r j
CMH Homes, INC rt. rr. �--�;;�.,.k�.�;'; ''•�' �'_ �,
ft. ft.—Facility/Owner Name Facility IC*(if applicable) ft. MAY 1 7 2024ft.
US HWY 19/North Side Drive, Lot 4 F.,,.,_..c x;•:-.�t
ft. rt.
!ras....'ta i,�-."'"' a U,:ii
Physical Address,City,and Zip
2 t:ftEviARKg . ;. , .. _;<< �_;
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 ladlong is sufficient) , •
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2/16/2024
N W Signature of ed Well ntractor;� Date
6.Is(are)the well(s): la Permanent or ❑Tern orary .p - By signing this forts,I hereby certify that the well(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 ONo copy of this record has been provided is the well osdner.
!/this is a repair,fill out knoun well construction information and explain the nature of the I
repair under 1121 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: 225 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2C I00') 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 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
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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.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
(
13a.Yield(gpm) 4 RIG 24c.For Water Supply&Injection Wells:
Method of test:
-PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county i ealth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water IResources Revised August 2013
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