GW1--04732_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM 'fO DESCRIPTION
Well Contractor Name ft. H.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER TI11C KNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 95 ft• 6.25 in. #21 PVC
Company Name MK INNER CASING OR TUNING(geothermal closed-loop)
JMQ-301 W FROM f0 DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft it. in.
List all applicable well permits(i.e.County,State.Variance.Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: most 10 DIAND-1 ER-- SLOT SIZE 1UWE:NESS_ NI:1TF:RI.u.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) D. ft. in.
( g g PP Y PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) FRi GROUT .ro M:1"fF:R1,1( EMPLACEMENT METHOD&AMOUNT
❑Irrigation • 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery
Injection Well: -_ ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(lfapplkable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FR"M To MATERIAL EMPLACEMENT METuoD
rt. ft.
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additionai sheets if necesaar))
❑Geothermal(Closed Loop) ❑Tracer FROM 1'O DESCRIPTION(color,hardness.soitrnck type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 95 ft. OVER BURDEN
613-2024 95 ft. 805 ft. GRANITE
4.Date Well(s)Completed: Well ID#_
ft. ft. r-- -- _
5a.Well Location: ft. ft. «t,._,r‘•• s• ).-LA.
LISA SPRINGER ft. ft. AUG 1 2 7024
Facility/Owner Name Facility IN'(if applicable) ft. ft.
# 12 SHADY WALNUT WAYNESVILLE, NC ft, ft tt, .:,A.i:.; 1"--r.,r ., ,
r'I.
Physical Address,City,and Zip 21.REMARKS
HAYWOOD 8646-05-0452 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 latflong is sufficient)
N M I.r-ift` 6-19-2024
Signature of ed eltractor Date
6.Is(are)the well(s): 2Permanent or ❑"Cemporary By signing this form,I hereby certify that the µells)was(were)constructed in accordance
with 15.4 A'CAC 02C.0100 or ISA NC.4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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. p e SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 at.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3(i11200'and 2Er 100') construction to the following:
Division of Water Resources,information Processing Unit,
10.Static water level below top of casing:460 (ft.)
If water level is above casing,use"-r" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the font 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:
tie.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
I3a.Yield(gpm) 1 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: 35 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