GW1--02958_Well Construction - GW1_20240513

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1
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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14,:W'ATFR>7ONFS Z:.... K: ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I !
4614-A ft. ft.
NC Well Contractor Certification Number 15.OlITER:GASLWG,(fOeliniltr-cased i ellifOI LINER(tf ipphcable)t ...:: M,
FROM TO DIAMETER TMCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft. 6.25 i to #21 Pvc
Company Name k6r.(31NER GASIl G,OR:TUBING(t eothernial'closed-lupp): ,
402289-2 FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
1.
List all applicable licable well (i.e.Coen State,Variance. etc,) .
1 p permitsn'.. Injection, ft. ft. iu
3.Well Use(check well use): • 17.;SGREEN..'.:: .
Water Supply Well: FROM , TO DIAMETER , SLOT SIZE THICKNESS , MATERIAL
ft. ft. in. .
❑Agricultural ❑Municipal/Public -
ft. it. ln'
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GAOUT m.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Dlrrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑iVlonitoriuug ❑Recovery ft. ft Cap Top with Bentonite Chips
Injection Well: ft. ft. .
OAquifer Recharge ❑GroundwaterRemediation RiSANDfGRAVELPACK(if lile s 1 a� nL .,,...r
EMPLACFM ENT METHOD
DATA fer Storage and Recovery ❑Salinity Barrier ft, ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
0 Experimental Technology ❑Subsidence Control 10.DRILLING:tOr(attieli addtttnuitl shceWitneeesstie); _, r ni.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiFrock type,grain size.etc.)
❑Geothermal(lleating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 90 R• OVER BURDEN
02/19/2024 90 ft. 305 ft- • GRANITE
4.Date Well(s)Completed: Well ID# "U.1 „
ft. ft. , _,i �'' .
5a.Well Location: �{.. _ ,.0.....i 1` ` .r
ft. rt. '"
Ray Real Estate Group ft. ft. MAY 1 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft.TBD California Creek Road, Lot 4 rre� ms-.•
fa ��'r,i17,--,;5,,,.,_ a It;,i
ft. ft. D Q13':,
Physical Address.City,and Zip 213tENIARICS'E §}W
Madison 9757-84-4032 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 IatAong is sufficient)
N W 2/20/2024
Sign of ed Well ntractor tr Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knows,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
S.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
t
9.Total well depth below land surface: 305 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3C200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (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:
(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 iCenter,Raleigh,NC 27699-1636
(gpm) 10 RIG 24c.For Water Supply&Injection Wells:
13a.Yield m 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. II
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources ' Revised August 2013