GW1--03510_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 l ,,5.1. —
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certilication Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 75 ft. 6.25 in• #21 PVC
Company Name 1t.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2021-20687-9-12393 FROM H. TO R• DIAMETER in. 1'HIt;KNESS NI Al t:KLAI.
List all applicable well permits(i.e.County,State, Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DIAMI:'IER SLOT SIZE THICKNESS MA FERIAE
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal Heatin Coolin Supply) OResidential Water Supply rt. ft. in.
( g/ g PP Y) PP Y
❑lndustrial/Commercial ❑Residential Water Supply(shared) tut.GROUT
FRUM TO MATERIAL. I.MEIA(EMEM'ME/HOD&:U1011\I
❑Irrigation 0 ft. rt.
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring ❑ReAxlvery ft. ft Cap Top with Bentonite Chip:
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) 5
FROM TO MA1ERIA1. EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier —
tt. rt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experi mental Technology ❑Subsidence Control
—
20.DRILLING LOG(attach additional.heels if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM 1'O DES(.RIP 1'ION(color,hardness.soil/rock type.groin size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
04-22-2023 75 ft- 705 ft. GRANITE
4.Date Well(s)Completed: Well lD# ft • ft V.. _
Sa.Well Location: ft. ft.
SHICK CONSTRUCTION/DENNIS HANSON ft. ' J U N 1 `l 2024
Facility/Owner Name Facility ID#(if applicable) --
324 BOAR RIDGE BALSAM MTN PRESERVE ft• ft. r' :l stedg "'',�,Yy uet
ft. ft. DI.C. '•:. ;
Physical Address,City,and Zip 21.REMARKS'
JACKSON 7672-50-4970 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)
04-22-2024
N W
Signature of ed ell ntractor Date
6.Is(are)the well(s): laPermanent or OTemporary By signing this Joan,I hereby certify that the uell(s)was(were)constructed in accordance
with/SA NCAC 02C.0/00 or ISA NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lEINo 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#1l 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 oft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3tp 200'and 2@100`) construction to the following:
10.Static water level below top of casing: 30 oft-) Division of Water Resources,Information Processing Unit,
flouter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)20 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.1)isinfection 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