GW1--03537_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger °' ° :;` ;
FROM TO DESCRIPTION
-I
Well Contractor Name ft. ft.
4614-A ft. ft. ]
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if opplicable)
F ROSt it) DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 133 ft• 6.25 in. #21 PVC
Company Name 16.INNER CASING,OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WEL2022-00222 FROM ft To ft mAntt:rER to THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) R, ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRont TO DIAMETER SLOT SIZE THICKNESS M-tFERIA1.
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
It, ft. in.
❑Geothermal (Heating/Cooling Supply) EJResidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROSt TO MATERIAI. I NDI,ttEMFNTSiE.l HOD&,%MOUA'I-
❑lrrigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring DRecovery ft._ ft _ Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if appticabl)
FROM TO MA"I FRLU._ ESIPLACEMF:NT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
LIAquifer Test ❑Stormwater Drainage
ft. ft.
17Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soitrock type.groin size.etc.)
IT[Geothermal(h(eating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 133 ft. OVER BURDEN
4-5-2024 133 ft- 205 ft• GRANITE
4,Date Well(s)Completed: Well ID# ft. ft• {_
Sa.Well Location: ft. ft. t*7.,`�`,e L..; y L Lit
BIG HILLS CONSTRUCTION LLC
ft. ft. JUN 1 2 2074
Facility/Owner Name Facility 1Dk(if applicable) ft. R
61 BRIDGE WAY DR CANDLER, NC 28715 ft. ft. trAs,tc ,i,;t o P- sRa -,g upl
Physical Address.City,and Zip Q 1r.' t .a
21,REMARKS
Buncombe 86986971730000 WELL WAS SELF CERTIFIED
County Parcel identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one fat/long is sufficient) -r' 1^�
N W 1 r��� 4-16-2024
Signature of ed ell ntractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
with 15.4 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 El No copy of this record has been provided to the well owner.
Br this is a repair,fill out known well construction information and explain the nature of the
repair under it2/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.'fotal well depth below land surface: 205 (f(,) 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 41;100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
((water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 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) 30 Method of test. RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: ZO well construction to the county health department of the county where
constructed
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013