GW1--06724_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: I
This form can be used for single or multiple wells • -
1.Well Contractor information: '
Taylor Ray Boger Ala:NYi11'ER'LQN>S..s V *4 1% tit
. FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
4614-A ft. - ft. !
NC Well Contractor Certification Number :'.15$,OVIER(;ASING3forliftiltiseased;Rel{s)DR L'1NER•(ifilp"'jiLeatile)i w,V, sMt;P
FROM TO DIAMETER 7HHICKNESS. MATERIAL
CLYDE SAWYERS &SON WELL& PUMP INC +1 fit• 47 ft• 6.25 in• #21 PVC
Company Name 41t lt!iNERteXSTI Ctic.ORsTUB1NC:(g""dti(bariusil•clo e'd-iiiiii° ; •• 6w 'i=,
408447-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 3?7 SGREENr ,.,4 •tftg•W %•1,. ": W Fi ,
Water Supply Well: FROM TO DIAMETER i' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. m
❑Geothermal(Heating/Cooling Su 1 elResidential Water Supply fit. fit. ;n.;
( €/ PPY) PPY
❑industrial/Commercial ❑Residential Water Supply(shared) 1h'GRnT1T ' �?� - ' ' `: em s „
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fit• 20 fit• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. ,Cap Top with Bentonite Chips
Injection Well: ft. ft.
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❑Aquifer Recharge ❑Groundwater Remediation et 9. i1NINGRA1'dal,P<ACtvi(if ap(tltcal le)"'; _I=M 14:Imo, ; `
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. ;'
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
,20s1)R11 11NGiEt)0(attie idaitini i(riSlie'ets if rieceacary) WWWIWAW q
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soit/rack type.gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 47 ft. !; OVER BURDEN
10-30-2024 47 ft. 305 ft. r.GRANITE
4.Date Well(s)Completed: Well ID# "- ,
ft. ft. c i n.1,.,'a `,' a '
5a.Well Location: ft. ft. ��.
RICKY SHELTON . ft. ft. NOV 1 LUZ4
Facility/Owner Name Facility ID0(if applicable) ft ft. 1 f f,3 t r .
., ,,,,
240 NORTON BRANCH RD MARSHALL, NC 28753 ft. ft. i, G):o;,,` ; ' "'
Physical Address.City,and Zip ' 1 zREN!<ARKSt' .,°';f'`,.:a °.4' € cxx.tM.two , . .W.,ai'i .. ",
MADISON 9729-26-7068 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 11-5-2024
Signature of ed ell C ntractor Date
6.Is(are)the well(s): CIPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 R'CAC 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 known well construction information and explain the nature of the I,
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 hells ONLY with the same construction,you can ,
' submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (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 c,200'and 2 crl00') 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,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.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: ! 1
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
5 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) .Method of test:PILLS Also submit one copy of this formn Within 30 days of completion of
13b.Disinfection type: Amount: 30 well construction to the county hea�lt1Y department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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