GW1--07510_Well Construction - GW1_20231120

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.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wens)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 22 It. 6.25 in* #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-00549 FROM 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): CA-2.-..i.:-f1I-TegitegarniMMUMMOMMINagirinifiigitnign
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) R. rt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) ts.GROIN
FROM ro
MAIFRIAL F:111.1.1(E NENI SIETHOI)& %WHIN"(
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Retxrvery ft. ft. Cap Top with Bentonite Chip;
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If appllvableej
FROM TO SMIFRIAI. FIIPLACEMENT NF.THUD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑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. 22 ft- OVER BURDEN
4.Date Well(s)Completed: 11-2-2023 Well iD# 22 ft- 305 ft- GRANITE
ft. ft.
Sa.Well Location: ft. rt. --
Jason Brock
ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft ft.
1179 Dillingham Road Bernardsville, NC ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 97404787500000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N M 11-10-2023
Signature of ed ell no ctor Date
6.Is(are)the well(s): )Permanent or ❑Ternpo ra
rY By signing this form,1 hereby certify that the n+ell(s)was(sere)constructed in accordance
with 15.4 NCAC 02C.0/00 or ISA 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#2/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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi_(jerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If miter 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 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 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONi.1': 1636 Mail Service Center,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 7 Method of teat
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount:30 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