GW1--03495_Well Construction - GW1_20240612

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.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
15.OUTER CASING(for multi-cased netts)OR LINER(if applica�)
NC Well Contractor Certification Number --I
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 23 ft. 6.25 in• #21 PVC
Company Name �' OR TUBING(geothermal closed-loop)
WP23-147 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable wr//permits 0.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply wail: EROM TO DI%MEI E.R SLOT SIZE TIIIC kNFSS M.A I ERR'.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) 1 ft. I ft. in.
❑IndustrialiCommercial ❑Residential Water Supply(shared) 1-)- (:ROUT
i_.F RO'SI t o sioI F:RIA). FAIN.%CEMENT METROD&:\MOUSE
❑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.SAND/GRAVEL PACK(if applicable) 4`
EROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
['Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control
211.DRILLING LOG(attach additional sheets if necessary) T
"'Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,hardness.soilrock type.grain size.etc.)
❑Geothermal(lleating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 23 ft. OVER BURDEN
5-10-2024 23 ft. 705 ft• GRANITE
4.Date Well(s)Completed: —Well ID# ft. ft. lI C. "' VE V
♦``iL..
Sa Well Location: ft. ft.
MONTE AND TARA OWENS ft. ft JUN 1 2 20Z4
Facility/Owner Name Facility ID#(if applicable)
ft. ft. IfliICVN CE4"rl 1Frr• �
7668 BLUE RIDGE ROAD LAKE TOXAWAY NC 28747 ft. ft. D'si-Cx 3t::;.,: um.
Physical Address,City,and Zip 21,REMARKS
TRANSYLVANIA 8514-48-8777-000 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) —r-'
N w 1 5-22-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary 8y signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15.4 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 EINo 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 82/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 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: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f different(example-le 3@200'and 2(d l00') construction to the following:
10.Static water level below top of casing: 'VA (g•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
li.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.)
Division of Water Resources,Underground Injection Control l'rogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013