GW1--01183_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger ;l4 VATER'ZONESMrsmsz ., r`%. Mz ': 4 .;,, v .3. 4.?Sk
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. .
NC Well Contractor Certification Number 'fi15 OUTERCASIN(;(fo%iiiultt-cased"hells):ORI1flERI(irappheable)"'=„ ` , , ,,.
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 24 It 6.25 #21 PVC
Company Name ,16:tlNNER;CASING.OWTUMG:(Reothet•miirelosed-toop�_ .�; 9 .'.
WEL2023-00167 FROM DIAMETERi THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.Count,State,Variance,Injection,etc.) It. ft. in
3.Well Use(check well use): 17 SCREEN ; .Z ,: n;: 4 W-<x N�T ,," S�:t;.. .ems �r.' �� ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply ft. fL tn•
( >r g PPP) PPP
❑Indusirial/Commercial ❑Residential Water Supply(shared) .,-woROLl,T�g', ,.x.�',. x,`,�;W ;,•`s .,_Poi, �. i . . s
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT'
❑Irrigation 0 ft• 20 ft• Bentonite' Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation M19',SAND/GRAVEVIrACIC(it-appticsble) : x AK' WaliM
FROM TO MATTERIAl. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It, ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
201DRIMING LOG;(att'ich"'addttioiial§heets:if uececsar})� MArIz 'fin 5 4
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 24 ft• OVER BURDEN
1-3-2024 24 ft• 805 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
ft. ft.
WILLIAM LANCE ft. ft. i' C .- -,--
Facility/Owner Name Facility ID#(if applicable) 4 4�' t' Z
R. ft.
21 GEORGE ALLEN RIDGE ARDEN,NC ft. ft. , FCr; I $ 2024
Physical Address.City,and Zip
Z1;REhI4RKS ,,., y:,v 1.n .- ,;t.
BUNCOMBE 1 CE r I I G ' ::
WELL WAS SELF CERTI�j�f�3�x,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one tat/long is sufficient)
N W � 1-15-2024
Signatunp-4
dI1 C ntractor Date
6.Is(arc)the well(s): ©Permanent or ❑Temporary
By signing this form,1 hereby certify that the tre11(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knowst 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 stone construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif different(example-3(i-42 00'and 2 rr1o0') construction to the following:
10.Static water level below top of casing: NA (ft•) Division of Water Resources,Information Processing Unit,
If water fete!is above casing,use"+" 1617 Mail Service Center,{Raleigh,NC 27699-1617
11.Borehole diameter: 5.25 (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: j
(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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 0 Method of test
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 d jpartment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013