GW1--04794_Well Construction - GW1_20240814

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
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• 75 ft- 6.25 in• #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
405145-2 —FROM TO DIAMFUER THICKNESS AtAi AI ERI .
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits tie.County State, rariancc.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: Hum 10 DI%MIA ER SLOt SIZE THICKNESS MATERLM._.—
R. ft. in. --
rJAgticultural ❑MunicipallPublic _
DGeothermal(Heating/Cooling Supply) PJResidential Water Supply(single) ft. ft. in.
( g PP Y) PP Y
El Industrial Commercial Residential Water Supply(shared) 18.GROLIT
FROM 10 AMATERIAI. F:MPLACEMENT MFali011&AMOUNT
nlrrigation — 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Re(rovery ft. ft. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation L19,SAND/GRAVEL PACK fit spplk*ble)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier - ft. ft.
LIAquifer Test ❑Stormwater Drainage — —
ft. ft.
El Experimental Technology ❑Subsidence Control
20.DRiLLIN)(attach additional sheets; try')
❑(isothermal(Closed Loop) ❑Tracer FROM t DESCRIPTION(color,hardness.aoiprnck type.groin size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
7-23-24 75 ft• 325 ft. GRANITE
4,Date Well(s)Completed: Well ID# ft. ft. -►.
Sa.Well Location: ft. rt. • -. l4v t D
TIMOTHY ROBERTS ft. ft. AUG 1 4 2024
Facility/Owner Name Facility(D#(if applicable) ft. ft.
599 OLD ELLER FORD ROAD MARSHALL, NC ft. ft. ,.; . -
Physical Address.City,and Zip �-
Dt, ,_.t3
21.REMARKS
MADISON 3735-36-5339 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 Iat/long is sufficient) —r—'
N W 1 7-25-2024
Signature of led ell ntractor Date
6.Is(are)the well(s): fr]Permanent or ❑Temporary By signing this form,i hereby certify that the swills)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or iS,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ErJ No copy of this record has been provided to the well owner.
!! his is a repair.fill out known well construction information and explain the nature of the
repair under h21 remarks section or on the back of this farm. 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 oueform. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdferent(example-3(u 200'and 2(c 100') construction to the following:
10.Static water level below top of casing: 60 (ft,) Division of Water Resources,information Processing Unit,
if water level is above casing,we"_.. 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: in addition to sending the fonn 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 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) 5 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 3� 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