GW1--04733_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 7izl.WATER ZONES
FROM TO DESCRI PI'ION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER 111ICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft. 6.25 ht. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
DCH016W FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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: FRo,At tU_ DI AA1E IER SLOT SIZE THICKNESS M.t FRIAt.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supplyft. ft. in.
( 6 != Pp Y) (single)
❑)ndustrialiCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM 10
MAT FRIA!. E\IPLAl L\IENT METHOD&AMOUNT
[Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
[Monitoring [Recovery ft. ft. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation , 19.SAND/GRAVEL PACK(if applicable)
FROM TO \1A7 ERIAI. EMPLACEMENT\MET11OD
❑Aquifer Storage and Recovery ❑Salinity Ranier
ft. rt.
[Aquifer Test ❑Stormwater Drainage
ft. ft.
[Experimental Technology ❑Subsidence Control
�-
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM '1'0 DESCRIPTION(color,hardness.soilrock type.grain sae.etc.)
[Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
6-19-2024 60 ft- 165 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft, ft. 7 `•-- ...,0 w i..,
Adrian De Jesus Fernandez ft. ft. _ AUG 1 2 2024
Facility/Owner Name Facility lDk(if applicable) ft. ft.
96 Windy Hill Lane Canton, NC 28716 ft. ft. I'`..:.;..:• i a • . .s •..; -
Physical Address,City,and Zip 21.REMARKS Haywood 8655-69-2070 THIS 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 6-24-2024
Signature of led ell arrestor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary 8y signing this form,I hereby certify that the twills)was(ware)constructed in accordance
with 15.4 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.
If this is a repair.fill out knottst 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:165 (fE) 24a. For All Wells: Submit this form within 30 days of completion of well
For tmdtiple wells list all depths if different(example-3C200'and 2C4100) 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
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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) Method of test: 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