GW1--01197_Well Construction - GW1_20240219

I.
WELL CONSTRUCTION RECORD For interim!Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: 1
Taylor Ray Boger t WAIT R.ZONE : W �
� AKIN 1,-,07 5 . `'"?
FROM TO DESCRIPTION I "
Well Contractor Name ft. ft.
4614-A ft. ft. I,
NC Well Contractor Certification Number 1S UUTER' A,50,1 (foiqmolti-a5e l*Us)":OR iL'NER<(rf`:lppltc tile] ,. ::`c y'
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 62 ft• 6.25 in;•' #21 PVC
Company Name = Ifi.11VNER CASINOOR:fi[IBINGx(( tlicitmiU cliiied-1a`iiji) ...':,:. :43.:iM.WA'',U0
FROM
2.Well Construction Permit#:WEL2023-00233 ft TO ft.
DtABIE'rER'lin THICKNESS MATERIAL
List all applicable well permits(i.e.Corurty,State,Variance,Injection,etc) tt ft. in.
3.Well Use(check well use): n1,7:4St?REEN," : ;0J1101 x K h
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in. —
f. ft.❑Geothermal Heating/Coolin Supply) OResidential Water Supply(sin le) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '''r$'GR(il'Gr ' ,= � 4 . :• ;i ...,,4;.' W "�`�' " n
FROM TO MATERIAL. , EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite' 1 Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRif 4XEI T'A ICtif appllraliie) Zsi21— ' "" ".:..
FROM TO MATERIAL'! EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
ft. ft. '
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control V
30hDRiELiNG2 ('atdeli.additionalisheets'Dfioec'ecsary), "su �, ,tom.
❑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 It. 62 ft. : OVER BURDEN
2-2-2024 62 ft• 385 ft• I GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. I.
5a.Well
ion:
P2427 HtOLDINGS LLC ft ft. o = ..L��ir 0
ft. ft. { L
Facility/Owner Name Facility ID#(if applicable) ft. ft. F t 6 1 9 2024
146 DIX CREEK NO 1 LEICESTER, NC 28748
ft. ft
Physical Address.City,and Zip 9ff f41,� .,fig ,)er. t
.x21 c�REl6IA12KS�'��� ;��"� �i�r.�t�.�
BUNCOMBE 9609973000 j
County Parcel identification No.(PIN)
'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: .
22.Certification:
(if well field,one tat/long is sufficient)
N W , 2-8-2024
Signature of ed ell ntractor Date
G.Is(are)the well(s): ElPermanent or ❑Cemporary By signing this form,I hereby certify that theimell(s)was(were)constructed in accordance
with ISA 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 BNo copy of this record has been provided to the hell owner.
If this is a repair,fill out knotn 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 wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (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'and 2G100') construction to the following:
Division of Water Resources;Information Processing Unit,
10.Static water level below top of casing: 80 (ft)
Ifirater level is above casing,use"T 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: in addition to sending the form 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent`r,Raleigh,NC 27699-1636
5 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
1 ,