GW1--02983_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 ri4:WATIelliZONtS -- 'in V. " W ,
FROM TO DESCRIPTION'
Well Contractor Name ft. ft. ! '
ft. ft. f
4614-A
NC Well Contractor Certification Number 1S OUTEBtG ti511 TG([or tnalft-cdseifft'As),ORLIIIER ff Appllcahlej ems:-x
FROM TO DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 78 ft• 6.25 'tn #21 PVC
Company Name � s 16 INNER;.d NG`SINOOICTUBI (i:e4t6grinili:elosedaoap) * .'
We12021-006V6 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) '
R. ft. in.
3.Well Use(check well use): �17SGREEN; �� �� ��= ��� h��.� �r
' NAM
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. rt in-
❑TndustriaVCommercial ❑Residettiial Water Supply(shared) 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 Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation , 19 SANDIGIDtVEEVA(IR(i[applicable) ? M, IXW. r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 1)RIDDI NC 1t7G,(atticti;addl0niiaf sliiii iF necevsnry) W l - s`
❑Geothermal(Closed Loop) ❑Tracer FROM _ TO DESCRIPTION(color,horsiness,soil/rock hype,groin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 78 ft. OVER BURDEN
12-18-2023 78 ft• 325 ft- GRANITE
4.Date Well(s)Completed: �Vcll ID#
ft. ft.
5a.Well Location: ft. ft.
--- r - -
Roy Lusk ft. rt. ti ;�. - --J::a{ -'4._,
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 1 Z024
•
241 Brookshire Fields Leicester, NC 28748 ft. ft.
Physical Address.City,and Zip :21 RENIA12KS': n : •. ij 'W,,"V
Buncombe 9700954373 i•'�s � �
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
Orwell field,one Iat/long is sufficient)
N W 12-22-2023
Signature of ed 1- `ntractor Date
6.Is(are)the well(s): ©Permanent or ['Temporary By signing this form,I hereby certibi that the well)was(were)constructed in accordance
with 15A hrCAC 02C.0100 or l5A NC.4C 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 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: 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. SUBMIT7'AL INSTUCTEONS i'
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9.Total well depth below land surface: 325 (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: i;
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mail Service'enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:I In addition to sending the fonn to the address in
ROTARY 24a above, also submit a copy ofl this form within 30 days of completiontof well
12.Well construction method: construction to the following:
(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
(gpm)40 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water 1eiources Revised August 2013