GW1--01157_Well Construction - GW1_20240219

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 �I4::WA ER(zO'Es A kM 0 W �� w � r c.
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I '
4614-A ft. ft. -
NC Well Contractor Certification Number
IS OUTEICCASINC(OFit altika iCwellsyOZLINER;(ifappUcablelA ,, Wi
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 ft. 6.25 j in. #21 PVC
Company Name +16:^INNERCASINt'OR TUBING;(ge4ftvermal eto`sed=loop}i ,W °%h
198408 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. j in.
List all applicable well permits(i.e.Coung;Stale,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 117/SCREEN., .x; . M v,x.. . ,a ,.,; p,z: , ,3.'Cg0
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. _ ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrialrCommercial :Residential Water Supply(shared) %k18 GROU1 a + � 4x. rV to t3,A . ,' 0.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. • Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation F9.1.82 )IGRA,OtEU;C?z1C ICk(if aTE IAl l`e)�.., `��z T:, ,
❑Aquifer Storage and Recovery ❑Salinity Barrier ROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater.Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control '
*20 DKILLING,3tSt^r,(nttach`adifiiilia`l"`sheetiltilececraii s 'MP..MMIlbtel
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 65 ft• OVER BURDEN
1-26-2024 65 ft• 225 ft. i GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. .-
5a.Well Location: ft. ft. i' 'i>m t.,t W: �kd t}
s.
Scott Reece ft, • ft. 9
Facility/Owner Name Facility 1Db(if applicable)
FEB 1 ��`7
�
ft. ft.
40 Pioneer Way Mars Hill, NC 28754 ft. ft. :> pa ten :'5;44t; U?i>
Physical Address.City,and Zip 41 I2.'En14R1CS 4 KIW W °IA �' t., 6 r 4
Madison 9.746-05-7792 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient)
N W ---rte 1-30-2024
Signature of ed ell tractor , Date
6.Is(are)the well(s): ©Permanent or ❑Temporary signing thisform,I herebye'er* that the well(s)was(were)constructed in accordance
�i' •s x e'er*
with 15.4 NCAC 02C.0100 or 15.1 NCAC 02C.0200 Well Construction Standards and that a
7.Is 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 known well construction information and explain the nature of the
repair under h21 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 INSTUCTEONS
9.Total well depth below land surface: 225 (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'mid 2C100') 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 Injection Wells ONLY:1 In addition to sending the fonn to the address in
ROTARY 24a above, also submit a copy of Ilthis 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 RIG 24c.For Water Supply&Injectio i Wells:
Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed. l
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013