GW1--02957_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: 1
Taylor Ray Boger gId ATEWZON s ' .: TA �j , .
C FROM TO DESCRIPTION
Well Contractor Name ft. ft. i 1
1 '
4614-A ft. ft.
NC Well Contractor Certification Number 15:<:UUTER CASING(focmnJtr-cased hells)OR[ NERAitrai hcabte) e•�y„
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 32 ft. 6.25 1°• #21 PVC
Company Name
6:[NNERVASTI Gr`.t3RAUB[NG:(Reotherr`uhI'ctosed.lonp) �:r �.:Va
403962-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Counq;State.Iiiriance,Injection,etc.)
ft. ft. ' in.
3.Well Use(cheek well use): ,,17i SOItEENR4 h:.O .a: us..a .....M i : ' a = .,. .. ,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.'
ft. ft.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) in.:.
❑Endustrial/Commercial ❑Residential Water Supply(shared) ,-A GROfit" '.�; z`"3 :, .- , i ,.K�.: 'j
FROM TO MATERIAL EMPLACEMENTMETHOD&1MOUN'r
❑Irrigation 0 ft. 20 rt. -Bentonite. Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. • Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation VI9 SAND/GR7lVU1 Pr1CIOif ifijiliailirVAVOPAM • c . ,g V,r WA
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
❑Experimental Technology ❑Subsidence Control
°26 DRTELING1100i(attielfiddrtiiiin lie'ailf CW6iary) " ,, 43' ,
❑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. 32 ft. OVER BURDEN
2-8-2024 32 ft. 225 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. I
5a.Well Location: ft. ft.
TRIPLE C BUILDERS `= 'i; a� ^_ -
ft. ft. (�
FacilityiOwner Name Facility 1D#(if applicable) ft ft. MAY I 2024
165 FLINT MORGAN ROAD MARS HILL, NC 28754 ft. ft. DrrE,xr,,;a-a Pr4;:s.E..?, -� ,,r,
Physical Address.City,and Zip 421 REMAR[CSWXWAag Sa`a*V `a"? a` t ^`+tO . ;
MADISON 9746-94-44984 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Certification:
Orwell field,one laUlong is sufficient)
N W 2-11-2024
Signature of red ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
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 DNo 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: 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. SUBMI'I"TAL INSTUCTEONS
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 if different(example-3@200'and 2@100') construction to the following: I
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 form 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: 1
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,!,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 6 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 health department of the county where
constructed. 1
1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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