GW1--03519_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
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.
NC Well Contractor Certification Number Ink7—Cli-1-7--ER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER 7Hl(KNF:SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 58 rt. 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal timed-loop) ;;'•
OSS-2024-0041 FROMTO
DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale.Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRONt TO DIAMETER_SLOT SIZE THICKNESS MATF.RLt1.
ft. ft. in. —
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) n. ft. in.
( >r 8 PP Y) PP Y
❑Industrial:Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MAl ERIAt, EMIT ACE MEAT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chipt
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applkable)
FROM -1'0 MATFRIAI, EMPLACEMENT MFTIIOD
['Aquifer Storage and Recovery ❑Salinity Bather ft. ft.
❑Aquifer Test ❑Stormwater Drainage
It. ft.
❑Experimental Technology ❑Subsidence Control
211.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain Sim.etc.)
17Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 58 ft- OVER BURDEN
4.Date Well(s)Completed: 5-2-2024 Well ID# 58 rt' 605 ft• GRANITE
ft. ft.
__
Sa.Well Location: R. ft. `' C C r'-i\v E?-1
LiJAMES&ANN BURTON ft. ft.
Facility/OwnerName Facility I :(ifapplicable) ft a JUN 1 2 ?024
201 FLATWOOD LANE MILLS RIVER, NC
ft. ft. {rrt43:1►tiA;•C. '.r,rtrroci:•;0/lire
Physical Address,City,and Zip 21.REMARKS
HENDERSON 9519967673 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN) WELL WAS HYDRO-FRACKED PRODUCING 2 GPM
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 5-20-2024
Signature of ed el tractor Date
6.Is(are)the well(s): (1Permancnt or ❑Temporary
By signing this form,1 hereby certify that the)sell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standard.s and that a
7.Is this a repair to an existing well: ❑Yes or El No 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
S.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. G C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:605 (rt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3)(4200'and 26 100') construction to the following:
10.Static water level below top of casing 80 tfL) 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 Iniection 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 SUPPLYr WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) L 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: 22 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