GW1--07483_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information: I
Taylor Ray Boger -14.t ATERZONES`- '_ -., m
FROM _ TO DESCRIPTION
Well Contractor Name
ft. ft. 1
4614-A ft. • ft.
NC Well Contractor Certification Number 15.OIJTER;CAS1 G(fur multi casis1 Wells)OR LINER(if an—livable) •; r.
FROM TO DIAMEI ER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 68 ft• 6.25 #21 l PVC
Company Name 16 dNNEWCASING OR TUBING(geothermal closed-loop)"„ `• _
JMQ-271 W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) ft ft. in
3.Well Use(check well use): q 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft In1
OGeothermal(Heating/Cooling Supply) RlResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 'F 18.ROUT xTti° MATERIAL EMPLACEMENT METHOD&AMOUNT
'
❑Irrigation 0 ft• 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :19 SAND/GRAVEL PACK(if app4i&ihle).----- - t, ., -^,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.'
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
-20.DRILLING LOG(attach additional sheets if necessary),r. '
r'
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,soil/rock hype.5rairi size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 68 ft•- OVER BURDEN
10/02/2023 Well no 68 ft. 225 ft. GRANITE
4.Date Well(s)Completed: ft. ft.
5a.Well Location: ft. ft
Aaron McKee ft. ft - _'
Facility/Owner Name Facility iD#(if applicable) ft. ft. NOV y J} (/Zn23
1128 Coyote Hollow Rd., Waynesville, 28785
ft. ft. lI __
Physical Address,City,and Zip
".216 -
REMARKS',:#.- .., a aF
Haywood 8619-57-8898 WELL WAS SELF CERTIFIED V
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient)
1 10/04/2023
N W 7 P ' i vi
Signature of I "'led Well .ntmctor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that the walks)was(were)constructed in accordance
with iSA:VCAC 02C.0100 or ISA A'CAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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#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 wells ONLY with the same construction,you cast
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-3 j200'and 2(0)100') construction to the following:
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 Infection 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1`� Method of test: RIG 24c.For Water Supply&Injection!Wells:
PILLS Also submit one copy of this fortis within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
•
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013