GW1--01185_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Taylor Ray Boger :.14::wA1E1VZONI!8. OO s,c tt ..0;: s,. •. ;,:`.,i
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
4614-A ft. ft. I I
#CIS:OUTER'CASING.(foe miiltecascd bells:{iR1LINER(if i pplicable ^•`:L
NC Well Contractor Certification Number ) )^� ,a �• `
FROM TO DIAMETERI THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 23 ff. 6.25 1 in. #21 PVC
Company Name 1`611‘INER CASINODWTi1BINiG(gei thcriuiil closed-loop) "'s~ "` ' '`AS:
We12023-00239 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. i in.
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3.Well Use(check well use): ??17t SCREEN =`G,„VSKAIPSAM R ` ' .v r:OW14, .- . '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in. '
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18::GROUTzs �` M ,.,.ur+ > . � : •Kj ' ,,4;tflfl '` '.-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite' Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. fit. Cap Top with Bentonite Chipt
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation 419:GSANllIGReC't ELPACKAif appliintile).„�� ,k •, ,ik:;4` ' ..: .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. I
❑Aquifer Test ❑Stormwater Drainage ft fit
❑Experimental Technology ❑Subsidence Control
z30 D1tILLINOlDpg(iitfie idclttin`iiiiiIheets'ifiliieSidi') w`VA C
❑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. 23 ft. i OVER BURDEN
1-10-2024 23 ft. 805 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. _
2020 Builders LLC ft. ft. " i''''"-• PV
Li
Facility/Owner Name Facility ID#(if applicable) ft, ft. l
Ftb 1 9 2024
George Allen Ridge lot 1 Arden, NC ft. ft.
Physical Address.City,and Zip c21ciREIS'MARKStn ,ift,r, g Mag9%F. s l i N-1 "1j 3
Buncombe •
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Well was self certified DecIQ/60G
County Parcel Identification No.(PIN) i.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient) '
N ""
W 1 1-15-2024
Signature of ed ell C ntracfor Data
6.Is(are)the well(s): Er7Permanent 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 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 knonsi well construction information and explain the nature of the I
repair tinder 1121 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
S.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. p G 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 if different(example-3Glu 200'and 2®100') construction to the following:
10.Static water level below top of casing NA (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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II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: 1niaddition 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: k
(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) 0 Method of test: RIG 24c.For Water Supply&Injection Wells:
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. I 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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