GW1--03511_Well Construction - GW1_20240612

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.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft, ft.
4614-A ft. ft. 1
NC Well Contractor Certification Number 1 S.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 58 ft. 6.25 in- #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-23990-9-1 2424 FROM 7O ft. DIAMETER in. THICR NESS M.AtE:RIAl.
2.Well Construction Permit#:
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: I•ROSI TO DIA5IFI ER -SLOT SIZE THICKNESS MAI F.RLAI,
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
['Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 1g.GROUT
FROM TO Sl.NI ERIAI. EMPLACEMENT METn01)&AMOUNT
❑hrigation 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) ;
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage — —
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,hardness.soi1rock tspe.gain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 58 ft. OVER BURDEN
4-16 2024 58 ft• 305 ft. GRANITE
4.Date Well(s)Completed: --- Well ID#
ft. ft. •,. ,�
'
Sa.Well Location: R. ft. : Y E D
`�``'' .. ,
RUSSELL FRANKS
it. it. JUN 1 2 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
494 E PINEY MOUNTAIN ROAD WHITTIER, NC 28789 ft rt. I110.,,,ra , .'" t
�'. Yam''',y s�'�
Physical Address.City,and Zip 21.REMARKSD'i'C...1'�� viy ,.
JACKSON 7547-90-8443 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
Sit.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
N ,1 �, 4-18-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): IaPermanent or ❑Temporary
By signing this form,I hereby certify that the twills)was(erre)constructed in accordance
with 15.4 NCAC 02C.0100 or I5A NC.4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or PINo 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 421 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: 305 (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 tt 200'and 2@l0or) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 70 (ft)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6'25 (in.) 24b.For lniection 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) 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: .30 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