GW1--06689_Well Construction - GW1_20241108

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger • <14 W,14'ERzo E8, ,.• :1, .. Axe :. 4;,,,;;
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. ft.
NC Well ContractorvCertification Number AS:OUTER GASP/C:.ter ifulti4d etI 4`ells)IOWLIIMCR.(if(ip llc'able)t. ,._.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 66 it. 6.25 in, #21 PVC
Company Name <f6>INNER'CAStNG:OR=•TCBING°(geo herrnal closed-loop);' :. =:ni/
WEL-2024-00577 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Vtu'iance.injection,etc.) ft ft in.
3.Well Use(check well use): , „_,1'1;SCREDNw z„ ,9,•L .a M I-. ,,.: a .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ID Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal Heating/Cooling Supply) ❑Residential Water Supply R• ft- in.
( PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 180GROt1T r ' . RIALU'l `
FROM TO M1A'rERIAL H11PLA(EMEhT METHOD&AMOiiN r
Oh-ligation 0 ft: 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifet Recharge ❑Groundwater Remediation a 19:SANDIGRAY:EL"VAt K(if ap'lic le} ,,<w ,. ;V)",: max, „ . , I,.
FROM TO MATERIAL EMPLACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑StormwaterDrainage ft, ft,
DExperimental Technology ❑Subsidence Control 20i;DRILLING%LOG(attach`additional sheets if necessary) :,'" w :3
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size.elc.)
❑Geothermal(Beating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 66 ft. OVER BURDEN
10-28-2024 66 ft. 285 ft• GRANITE, _
4.Date Well(s)Completed: — Well ID# ft ft. 4 't ,R„ )• , •:
5a.Well Location: ft. ft. . syl
JEFFREY TAYLOR ft. ft. N(IV 0 8 2024
Facility/OwnerName Facility lD#(if applicable) R ft. • Ir'"'e:a, :.-. r'^^•.: ,` a)
17 FAIRFIELD DRIVE CANDLER, NC 28715 - ft. " ft. L ,:;:. J v
Physical Address,City,and Zip 421t,REIKiARKSA ,. t .•:'`r"` A' k :" ti ,.ff .' -- .fit Y
BUNCOMBE 96079448290000
THIS WELL WAS SELF CERTIFIED -
County Parcel identification No.(PIN)
' Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N ,l, —rip 10-29-2024
Signatud ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑'Cemporary By signing this form,I hereby certify that the well(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 ENo 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 1121 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 saute construction.you can
submit one form. SUIMl1"1'AL INSTUC'L'IONS
9.Total well depth below land surface: 285 _ (ft.) 24a. For All Wells: Submit this term within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(a1.200'and 2@100`) construction to the following: •
30
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level i.e above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For injection Wells ONLY: Id 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
(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
40 RIG 24c.For Water Supply&Injection Wells:
(gpm)
13a.YieldMethod of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 28 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