GW1--03502_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Ilse ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM TO DESCRIPTION _
Well Contractor Name ft. ft.
4614-A ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 Ft 95 rt• 6.25 #21 PVC
Company Name It.INNER CASING OR TUBING(geothermal closed-loop)
389976-2 FROM _ 'rO DIAMETER I THICKNESS VIAl ERIAI.
2.Well Construction Permit#: ft. ft. ia.
List all applicable well permits(i.e.County,State,Variance,injection,tic.) ft, It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM "10 DtAME't ER SLOT SIZE THICKNESS MAATERIAI.
ft. ft. in.
❑Agricultural ❑MunicipaVPublic _
D. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)❑lndustrialiCommercial ❑Residential Water Supply(shared) 1$.GROUT
FR01I TO MAIERIAI. EMPLACEMENT ME IIIOD& AM0115'1
❑irrigation 0 it' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring CI Recovery ft. ft. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL F:SIPI.ACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rt. rt.
❑Aquifer Test ❑Stormwater Drainage —
ft. ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,hardness.sot Wrack type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. OVER BURDEN
3-25-2024 95 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft
5a.Well Location: ft. ft. I- ., i";t
TRAVIS FOX �" ' ��L'.
ft. ft.Facility/Owner Name Facility lO#(if applicable) f ft. JUN 2024
MORLINS ACRES DRIVE LOT 17 MARSHALL, NC28753 ft. ft. IfiQti:R-, ;,1 31
arc. a :ice
Physical Address,City,and Zip 21.REMARKS '��i
MADISON 9725-009308 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 %� 3-26-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): 13 Permanent or ❑Temporary By,signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15.E NCAC 02C.0100 or 15A NCAC 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 to the well owner.
/f this is a repair,fill out known well construction information and explain the nature of the
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: 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3(w200'and 2(4100') 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
t i.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 Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 2O 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