GW1--06712_Well Construction - GW1_20241108

1
I
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 rl4 vf1TERr2t)`EB . z M: , : , a'OZ :h
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number iSMNITER;.CASING fideniulitseased<;tsills�'inINEArtit'; p Leabl :��' :`,
FROM TO DIAMETER• THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 83 ft 6.25 'in• #21 PVC
Company Name 101NNER:CAST14tx"OR%TUBING(:eottiMiiiiltctosetl-loop)` aY.0 :i.
WEL-2024-00469 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits tie.County,State,PM-lance;Injection,etc.) R ft. ,in.
3.Well Use(check well use): ?17 SCREEN 1 x:k,R -0 ., i 7,AVAM
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R ft. ,n.
❑Industrial/Commercial ❑Residential Water Supply(shared) pis:GRn1lT; '51 �'" .- ' ``4` 1 `." r
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN'T
❑irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chipf
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PAM(if apjillcakile)M iwMMMM�` s�`V ` s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Battier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
"f2I0DitIELING1001attiil additionalrSh et'sifnicessary) 7K �� at
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc-)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 83 ft. OVER BURDEN
10-15-2024Well ID# 83 ft. 205 ft GRAi�.ITE 7; --
4.Date Well(s)Completed: ft ft. t.,,,�.1.,.'•A,..::: 'f1!.,va �i
5a.Well Location: R. ft. • NU V 0 8 2024
BOB CANE CREEK PROP LLC ft. ft.
Facilit/Owner Name FacilityIDka applicable) Ir'� ;...r: �-':' -:,--
Y (ifPP ) ft. ft. ..^,-L.filke
2040 SAND HILL ROAD EST CANDLER, NC 28715 D±icti s`'`3
ft. ft.
Physical Address.City,and Zip 21 REMARKS M:30, , .; ii `a (?: '12-utomm
BUNCOMBE 9617812056 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well field,one lat./long is sufficient) '
N W 10-18-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): l Permanent or ❑Temporary By signing this form,I hereby certify that the we11(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 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 I
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 same construction,you can
submit one form. SUBMI1TAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200"and 2(a.100`) construction to the following: 1
10.Static water level below top of casing: 30 (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 fonn 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei ter,Raleigh,NC 27699-1636
I3a.Yield(gpm) 15 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: 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