GW1--02956_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD For Internal Use ONLY: ,
This form can be used for single or multiple wells ,
1.Well Contractor Information:
Taylor Ray Boger �4:wATER3ZON>s.� _ k k 4 . x wzam .: .,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I
15.-4UTERVASING(far`tp6ltt-casedxs1 32 6 25ells)'f3R i 1NER(if:appLcahle)'=
NC Well Contractor Certification Number
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC + ft• ft, i in. #21 l PVC
Company Name
lfii-INNERVASINGOR::TiIBINCTT(geothermnl;closed-tuap)
403962-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ; in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. i in.
3.Well Use(check well use): 17.cSl BEEN. ss " u, 'Uj Mi ,55&` nVi ; 5
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. fL in.
❑Geothermal(Beating/Cooling Supply) elResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) r18:GROUT?a-, " — "'. -• ' '
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 Chipt
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.8AND'/GRe1YEEFr1C;K`(if.apjili661e}5 ; lam: ,1, 'Ag:
❑Aquifer Storage and Recovery OSalinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
:2'10 s 1RILLINGtFI,f?C'r`.(attie&sddtdiinil;sheets.irliV6sur} 7;':
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 32 ft. OVER BURDEN
a.Date Well(s) 2-8-2024 32 ft- 225 ft. j GRANFTE-- - •
-
( Completed: Welt ID# kk � ;� L'
ft. ft. G �.- ,.i 3,-,
Sa.Well Location: R. ft.
TRIPLE C BUILDERS MAY 1 ?104
ft. ft.
Facility/Owner Name Facility iD#(if applicable) :
rri:k Fv.q�, +n_ .v; t J,`e
ft. ft. tfi'FP,
165 FLINT MORGAN ROAD MARS HILL, NC 28754 ft. ft. ' "0"1-Y�-10P.i
Physical Address.City,and Zip ',21 REA'I41U S M. W/MMWM a ' , ?. -A „, °al
MADISON 9746-94-4984 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
514.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient) is
N W ellIA. 2-9-2024
�®
Signature of ed ntractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this fortes,I hereby certify that the well(r)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 DNo 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#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: 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: 225 (ft.) 24a. For All Wells: Submit this'.form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@ a200'and 2 100`) construction to the following: ,
10.Static water level below top of casing: 50 (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: I;inaddition 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.) j
Division of Water Resources,IUnderground Injection Control.Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) 6 Method RIG 24c.For Water Supply&Injection Wells:
13a.Yield m 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 department of the county where
constructed. I i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water RI sources Revised August 2013