GW1--06753_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Taylor Ray Boger 1.4MVATERPZOvEs .1i MIPM,, 3: t
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. ! ; •
NC Well Contractor Certification Number IS"OUTERxC'ASIN (for m"uliregii1Reffs);1WELNER(tf ap+Itcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 75 ft. 6.25 ; in' #21 Pvc
Company Name d fNf4IER CASI14CxOR'tTUBING(aeo(tiermiilitlosedaoop)hV+ s ° .aF,`''hR`8
010924-1 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): 1174St3REENA M. Of x :-T
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ZJResidential Water Supply(single) ft ft. in. .
A1V❑Industrial/Commercial ❑Residential Water Supply(shared) ERoGnfRDUT� Tr � T�AL � EMPLACEMENT METHOD&��ot rRY
❑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 " ❑GroundwaterRemediation x.19rS011/IGRAVELI'AVIC(ihap(Ella»810 :rZala`kwa 4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM CO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater.Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control ,
,20 DRILLINOEDG(aEtifehltdilitr"`+ furl eetg.rtnecest:tii) ' . ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
8-9-2024 75 ft. 305 ft. GRANITE
4.Date Well(s)Completed: Well ID# :r" - •ft. ft. i)N y:-,-. -. e
_
5a.Well Location: ft. ft I �D, f j.�' .'
ft.
SHERMAN PARRIS ft. ft. NOV 1 2 2024
Facility/Owner Name Facility lD#(if applicable) ft. ft. ,• _ -.,. p„t;- ,=t =
64 SAMS HOLLOW FRANKLIN, NC 28734
ft. ft. D'i-j..i:'1.):.:i
Physical Address,City,and Zip 3a21 REIWARK AW , ..) a'' ' W'M
MACON 6582475061 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN) I
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w 7'' �s 8-15-2024
Signature of ed ell ntraclot Date
6.is(are)the well(s): Ir7Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Ls this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knouim 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 i
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft) 24a. For All Wells: Submit this iform within 30 days of completion of well
For multiple wells list all depths df different(example-3@200'and 2c 00) construction to the following: II
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
f„suer level is above casing,use"4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: 1n 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.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C`nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test:
RIG 24c.For Water Supply&InjectionlWells:
PILLS 30 Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. 1
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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