GW1--03509_Well Construction - GW1_20240612

• WELL CONSTRUCTION RECORD For lntemaI I.,e IINI l'
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROST TO UFM ItIP1 ION
Well Contractor Name ft. ft.
4614-A lt. D.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM 'If) DIAMtl ER 'THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 75 ft. 6.25 in• #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-25705-9-13258 FROM IO ft. DIAMETER in. THICKNESS MAFERIA
2.Well Construction Permit#: ft. I.List all applicable well permits(i.e.County.Stare,Variance,Injection.etc.) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMF TER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
DAgricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) OResidential Water Su I sin le ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 n• 20 ft Bentonite Pumped
Non-Water Supply Well: - —
❑Monitoring ❑Recovery it. tt. Cap Top with Bentonite Chips
injection Well: — — — ft. L IL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
F I(O\I MATERIAL _ EMPLACEMENT METHOD
❑Aquifeer Storage and Recovery ❑Salinity Barrier D. ft.
❑Aquifer Test ❑Stormwater Drainage — ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soilrock Ispe,grain size,etc)
oGcothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 lt. OVER BURDEN
4-15-2024 75 n- 245 t.'• 'GRANITE,...
4.Date Well(s)Completed: --Well ID#
�
ft. n. �L.LP�.: ,•
5a.Well Location: ft. ft.
JOSEPH WHEELIHAN JUN 1 2 2024
ft. ft.
Facility/Owner Name Facility 10k(if applicable) rt. ft. ia4t,.tsTi6c;,: i'-rr, ;',.U
ftit
512 BRENDLE ROAD BRYSON CITY, NC 28713
ft. � ft.
Physical Address,City,and Zip 21.REMARKS
JACKSON 7604-31-3883 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one let/long is sufficient)
N K, 04-29-2024
Signature of led ell ntractor Date
6.is(are)the well(s): 63Permanent or ❑Temporary By signing this form,I hereby certify that the wr/l(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15.4 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 well owner.
((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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (fU) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (f ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"t'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 Iin.) 24b. For Iniection 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:
(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) 10 Method of test: RIG 24c.For Water Supply&Injection'Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection PILLS Amount: well construction to the county health department of the county where
hpe:
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013