GW1--06686_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD . ; For Internal use ONLY:
This form can be used for single or multiple wells . ,
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I.Well Contractor Information: -
Taylor RayBoger utEva l wza; is �°� ,� 4 �m :C ,, ,z,4
, FROM TO ' DESCRIPTION
Well Contractor Name ft. ft. I I •
4614-A ft. H.
NC Well Contractor Certification Number • IS'CtUTCRCASING.(fuc'mult 'ilsceftiMItc1INEft'(IC, L"ciitile►r .:V1PMV,.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL& PUMP INC +1 ft. 103 ft. 6.25 in. #21 PVC
Company Name 'Aril'ti INN'F.R t,i1.SI't?lja,MTVIONC(g tifhenmal'c!nsed4bQP) .,<'J/#
2023-00468 • FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. m.
List all applicable well permits(i.e.Cmmi);Stale.Variance,Injection,etc.) ft. ft. i in.
3.Well Use )(check well use .
41VSGREENy ff ;. ' � .�xN F MWiiao:s tom :..
Water Supply Well: FROM TO DIAMETER ; SLOT SIZE • THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public"
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. In.
❑industrial/Commercial - ❑Residential Water Supply(shared) tB CRt5 '' ''.a I4V'� �``; 5 METHOD 24: " '`
FROM TO MATERIAL EMPLACEMENT &AMOUNT
Elimination 0 fi. 20 ft. Bentonite, Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. ,, Cap Top with Bentonite Chip:
Injection Well: ft. ft. ':
❑Aquifer Recharge ['Groundwater Remediation 79..iSANDtGRiti?,'ECI">MKV(itapiitt lice) ` ?,,r : 1 IMMA. *OV
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft• ft. 1•
,
['Aquifer Test ❑StormwaterDrainage j
. ft.
❑Experimental Technology ['Subsidence Control , s r,'> 4
E
2ltilDitlr l;INi WG(attacliaddltaoanlisftt:ets iCnieceiiiiii`
❑Geothermal(Closed Loop) ,❑Tracer FROM TO, DESCRIPTION(color,hardness.soil/rock hype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) .❑Other(explain under#21 Remarks) 0 ft• 103 ft. ;' - OVER BURDEN
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10-29-2024 103 ft. 265 ft. GRANITg ,,.. -,,,_,.
4.Date Well(s)Completed: Well ID# rt. ft. . • ,A. ; a., g`�,
5a.Well Location: • ft. ft.
ANTHONY GREEN ft. ft. . ' NI)U 0 S 2021 •
Facility/Owner Name • Facility MI;(if applicable) ft, ft. I' if.:,:..,;.• ,i. ;. ?rr_'-'.--,:�: s`Y
36 PINNACLE PARK ROAD WEAVERVILLE,NC ft. ft. L°� �� ;-�J
Physical Address,City,and Zip 41t1REl11A ,M00-.W" : !" i z"` `I,A`` W,:atMain,4
BUNCOMBE 974242227300000 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: •
(if well field,one lat/long is sufficient)
�— • 11-6-2024 '
N W Signature of ed ell ntractot . Date '
6.is(are)the well(s): t 1Permanent or ❑'temporary
By signing this form,I hereby certI that the nee114)was(were)constructed in accordance
with 1514 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a •
7.Is this a repair to an existing well: DYes or ONo copy of this record has been provided to the stall owner.
lfthis is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks section or on the back of this form. 23.Site diagram or additional wellIdetails:
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: 265 (ft) '24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(csarnple-3@200'and 2Ga'100`) construction to the following: . I' , . '
10.Static water level below top of casing: 40 (ft.) Division of Water Reso(Frees,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6'25 (in.) 24b.For Injection Wells ONLY: In. addition to sending the form to the address in '
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY , construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) , r .
Division of Water Resources,Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
15 RIG 24c.For Water Supply&InjectiontWells:
13a.Yield(gpm) Method of test: r
Also submit one copy of this form Within 30 days of completion of
PILLS
13b.Disinfection type: Amount 25 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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