GW1--05625_Well Construction - GW1_20240916

WELL EL,L CONS'i'R[1C'FI®N RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells
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I.Well Contractor Information:
Taylor Ray Boger 1* \vA1{ER;L(?NI`S` �i m lr "'." li 'e t.. k ,. , r,e,;'(> "`'`' .``s#„ '
FROM To DESCRIPTION
Well Contractor Name ft. ft. I 1
4614-A ft. ft.
NC Well Contractor Certification Number s'15,:aOUTCR ASING.(for<<nitiitkaipi hells)DWL�`NER(If"ap)rLcatile") :;,s :?,
FROM . TO DIAMETER 11IICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft. 6.25 in. #21 PVC
Company Name IG.WINE C.vYSINWOR 7'fIBINGI(giGplhernut'1 clliicdillit}i) ,ma=:s,
2.Well Construction Permit#: 2023-24830-9-13869 FROM ft. TO ft. DIAMETER 'in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): w VSCRREN,,.. ,. #Ws`:a ....N 5, ` r.x r. Wig.t. . mil;
Water Supply Well: FROM 'r0 DIAMETER .SLOT SIZE THICKNESS . MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geotherma( Heating/Cooling Supply) F.iResidential Water Supply(single) ft. ft. in.
( PP Y)
❑industrial/Comnrercial ❑Residential Water Supply(shared) =1S"GROVI'�&'"` ''�" s ; " �'' 4 '
FROM TO MATERIAL'RIAL 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 t19:SAND/GRA':Y.LAP.c\t?1+:=(if,n)inlicK6)e)x,",>,M :c „ )f, ,gW %
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
R2O.DRILL,1NG Gtnftaccleaddr6iiithN'hcetsafueetwilrlf- 'R ',;:,,F
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soilrock type.undo size.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 70 ft. • OVER BURDEN
8-14-2024 70 ft- 125 ft• GRANITE
4.Date Well(s)Completed: —Well ID# ,
ft, ft.
Sa.Well Location: ft. ft. '
CYDNEY IAMAIO ft. - ft.
Facility/Owner Name Facility 1Dk(if applicable) ft • ft.
LEWIS COVE ROAD SYLVA, NC 28779 ft. ft.
Physical Address,City,and Zip
P 621:?gIVIARICu, ' VVVA -1.M4 S 7 ` .tM 00
JACKSON 7603-52-7217 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: i
Orwell field,one lat/long is sufficient) .
N W 8-27-2024
Sienature of led ell ntractor • Date
6.Is(are)the well(s): lIPermanent or ❑'Pemporary By signing i g this farm,1 hereby certify that the mall(,)was(were)corrvtnwie'd.in.•eccmrianap
•t,'n�e _
with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrttcti n.Standis ds yn'd'thsYt i, '
7.Is this a repair to an existing well; ❑Yes or ElNo copy of this record has been provided to the well owner.
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If this is a repair,fill out known well construction information and explain the nature of the n
repair under tf21 remarks section or on the back of this form. 23.Site diagram or additional well details: S E P 1 13 2024
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages}ftnsewgf iip7...ru-,,zz.7.1 1
For multiple injection or non-water supply wells ONLY with the same construction,you can iPj ri.' O i
submit one form. SUBMITPALINSTUCTIONS i
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion o1'well
For multiple wells list all depths if different(example-3@200'and 2C 100') construction to the following:
10.Static water level below top of casing 20 (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 (i►►.) 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: u
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set-vice Center,Raleigh,NC 27699-1636
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13a.Yield(gym) `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
I3b.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
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