GW1--06693_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD Forinlei'nal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger t14:,WATERZONES:, . . ?44r,'a -
. - ,. ,. . _. ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4614-A ft. fL
NC Well Contractor Certification Number IS.OUTER"CASING(forInultr cased,t ells)OR LINER(if Op`Reable)'1';':; ;;',1-'..
FROM TO DIAMETER THICKNESS MATERIAL -
CLYDE SAWYERS & SON WELL & PUMP INC +1 fL 101 ft- 6.25 in. #21 PVC
Company Name ,A, 16.INNER'CASING OR TI.tBING(gei the mal closed loop)°' "'
2.Well Construction Permit#: V V E L-2024-00449 FROM ft. ft•TO DIAMETER rm THICKNESS MATERIAL
• List all applicable well permits(La County.State,Variance,Injection,etc.) fL ft. in.
3.Well Use(check well use): 'I7.SCREEN_ 1 ', '.. '' t/...-Z;,' ,-,r ,=,, .{ . '4', a.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `•18.GROUT ; ` � . ram`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery .
Injection Well: fL ft.
❑Aquifer Recharge ❑Grotmdwater Remediation '19.:SAND/GRAVEL PACK',(Ifapfplie'lli e) T.,,... ,.-,--
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft. .
❑Aquifer Test ❑Stormwater Drainage ft. ft.
0 Experimental Technology 0 Subsidence Control -'20:DRILLING-LOG(attach Iddidonnlsbeetsafdecessarr),. ..; v T
❑Geothermal(Closed Loop) ❑Tracer • FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)'
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 101 ft, OVER BURDEN
10-18-24 101 ft, 365 ft. GRANITE
4.Date Well(s)Completed: Well ID# ,.
ft. ft. ` f
5a.Well Location: t.: `( .,1.--t a
ft. ft.
DELBERT J MATTHEWS ft. ft. NUV 8 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
86 YOUNG DRIVE Irr:,:;;-_,.,--- .,
ft. ft. L c i 0 ✓ vx
Physical Address,City,and Zip
CANDLER 8697-05=6487 >xixENlARxs,�•;�, . .�, , 1�, ;r�..- -, �ti- ,t ._,�;; _p
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 latllong is sufficient)
N W r. 10-23-2024
Signature of led U ell ntractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary
By signing this form.I hereby certifii that the well(s)was(were)constructed in accordance
with ISA:VCAC 02C.0100 or ISA 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 known well construction information and explain the nature of the
repair under#21 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
subunit one form. SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface:365 (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@200'and 2Q100) construction to the following:
i
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 Iniection Wells ONLY: j 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.) t
Division of Water Resources,pnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
6 RIG 24c.For Water Supply&Injectio I Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this fonn within 30 days of completion of
13b.Disinfection type: Amount:25 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