GW1--04734_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 TO DF:SCIO IION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number : OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 n• 75 0• 6.25 in. #21 PVC
Company Name /►� FROM16.INNER CASING OR TUBING(geothermal closed-loop)
DGS'O83YY FROM
TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R. in.
List all applicable we'll permits(i.e.County,State.Variance.Injection,etc.) R. it. in.
3.Well Use(check well use): 17.SCREEN ,,'
Water Supply Well: IRON To DIAMETER SLOT SIZE TIIR KNESS ML%IERLM.
-- ft. ft. in. — ---- ---
❑Agricultural ❑Municipal/Public _
ft. rt. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
❑industriabCommercial ['Residential Water Supply(shared) IF GROUT
ROM TU I M VIFRIAi. E5ItLACEMEN1 METIlon St ASIOUA7
['Irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
it' ft. Cap Top with Bentonite Chip,
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 19.SAPID/GRAVEL PACK(if applicable)
FROM TO MATER/At. EMPLACEMENT METHOD
DAquifer Storage and Recovery ['Salinity Barrier ft. ft.
Ill Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock hpr.grain size.rtr.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 75 n• OVER BURDEN
4.Date Well(s)Completed: 6-18-2024 Well ID# 75 ft 225 ft. GRANITE
ft. ft. '--
5a.Well Location: R. R• tF 0-'.;.., ,,,•
,MOUNTAIN INTERNATIONAL LLC * '� -�
ft. ft.
1 2 2024
ft.
Facility/Owner Name Facility ID#(if applicable) D R.
LOT 10 PENNY LANE WAYNESVILLE, NC 28785 If,-- ;
ft. ft.
Physical Address,City,and Zip 21,REMARKS
HAYWOOD 8608-67-9212 THIS 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 lat./long is sufficient)
N W (�Nn ' 6-25-2024
Signature of ed ell ntractor I Date
6.Is(are)the well(s): ®Permanent or ['Temporary By signing this form,i hereby certify that the tuell(s)was(were)constructed in accordance
with 15.4 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 Erl No copy of this record has been provided to the well owner.
11-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 yells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 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(a 100') construction to the following:
10.Static water level below top of casing 40 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Injection 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 8 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 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