GW1--06656_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 14,AvA >r>zvzt) s .,4 ,z,, wv,_ .,f.. . , o
FROM To DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. It. i.
• NC Well Contractor Certification Number 15;0UTER EASIN'G(fdr,ri ultr euiar,,i ls)OR LINER(If tsp i ticable)5°x .-x
FRONT To DIAMETER 'THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft• 82 ft. 6.25 1 in. #21 PVC
Company Name 16:5NNER CAS1NG•OR.TUBt G(geothcrinal closed loop)i`,„
OS�+-2024-���� FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: 0 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use):
:47:SCREEN a .,M. , .'.
Water Supply Well: FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. - ft. m
['Geothermal(Heating/Cooling Supply) 17Residential Water Supply(single) ft. ft• in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS:GROUT .:•''' ., ° t ' '` r
FROM TOG MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. Cap Top with Bentonite Chip:
[Monitoring ❑Recovery
Injection Well: ft. ft.
[Aquifer Recharge ❑Groundwater Remediation :I9.SANDIGRA'VEL:PAC,YG(ifa#PHeahle) R. t R '; ...r_.,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.-DRII;LING.I.OG:(attachadditloiialsbtits°itneeessar14} ii att",ttats, .•, _`;`
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soitlrock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 82 ft. if OVER BURDEN
07-15-2024 82 ft• 285 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. ' _
7.
5a.Well Location: ft. ft. ! @~:ti;�10.t,:,+i�.�.; ty i1...,L
HOMES OF CLAYTON/CMH ft. ft. \I 1 S '074
Facility/Owner Name Facility ID#(if applicable) ft. ft.
110 WHISPER MTN RD ft ft.
r ..
I I ifJ Physical Address,City,and Zip ::21.Rl'MARES.,gig . ': ,... „; ,'G ;=o , 5-"
HENDERSON 061 17562'21 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PEN)
I
. 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w Ehg_ . 07-15-2024
Signature:of red ell ntractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certijjr that the well(s)was(were)constructed in accordance
with 15.1 NC:AC 02C.0100 or 15A NC AC 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:will owner.
!Phis is a repair,fill out known well construction information and explain the nature of the
repair under#2i 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.'l'otal well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdjerent(example-3Q200'and 2C100) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources•,information Processing Unit,
if water level is above casing,use"+' 1617 Mail Service Center,IRaleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Injection Wells ONLY: Iniaddition 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 Centl r,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 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: 20 well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013