GW1--02981_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 k14:W,•ATgrOzONtSVAMSE,"r OV=47r 41,Wy: SAVOMM .m
FROM TO DESCRIPTION'
Well Contractor Name ft. ft.
4614-A ft. ft. 1 !
NC Well Contractor Certification Number iiMOUTER`CASING(folliitiltt cooed i'ells)"ORILINER'(if tiiti i lieahle) " h,=
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 102 ft, 6.25 i,in• #21 PVC
Company Name ;:lt'r,INNER,Cr1SING'ORiTLIBING.( eotbermat'clased9otip}t 'n,.�'1`A
WEL2023-00482 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. in.
3.Well Use(check well use): ,.13:SCREEN s :,r,W,s.,;� .r u:1=.: Me w n. s .` :.s '-%
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft• ft• in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) hI8GRnET M' " '= `1114 `4<°1'4"' ' `
FROM TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
['irrigation 0 ft 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation #.19 SANDIGRAVEL EACKtifatiiilt`ctible)` r` . IMMOWlea M ; ' #
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater.Drainage -
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
211 ORiLLTSGILit:•(attach•addihnnsirilieefkiffecevsar})aNgl i 1
❑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. 102 ft. 1, OVER BURDEN
3-18-2024 102 ft• 445 ft• I GRANITE
4,Date Well(s)Completed: Well ID# ft ft. c.'. C. Ai b'
Sa.Well Location: ft ft,
ZACKARY&MIKHAYLA SLUDER ft ft MAY I ,3 2024
Facility/Owner Name Facility IDk(if applicable) ft. ft. kri .-< :
111 ALEXANDER VIEW ROAD ALEXANDER, NC "''"" `£�� �
ft. ft. {. 1.1' etro "
Physical Address.City,and Zip :41VREMARKS TM'r VV; ��trik '"WW Vie'
Buncombe 9722518356 WELL WAS;SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one IaUlong is sufficient)
N W "1—G h %t1.1-1, 3-21-2024
Signature of ed ell tractor Date
6.Is(are)the well(s): ®Permanent or ❑'temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.A 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[lie stall owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 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
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 saute construction.you can
submit one form. SUBMPI"1•ALINSTUCTIONS
9.Total well depth below land surface:445 (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 2@100`) construction to the following: li
10.Static water level below top of casing: 60 (ft.) Division of Water Reso trces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I i
11.Borehole diameter: 6.25 (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:
(i.e.auger,rotary,cable,direct push,etc.) l '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) 3 RIG 24c.For Water Supply&Injection Wells:
m 73a.Yield Method of test:
PILLS Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: Amount 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013