GW1--07521_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 DEM'RIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LLNER(if applicable)
FROM TO DIAMETER 111IC'KNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 88 ft. 6.25 in: #21 l PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)<,
2022-00405 FROM TO DIAMETER THICKNESS MA1FIlI11.
2.Well Construction Permit#: it. ft. in.
List all applicable well permits(i.e.County,State,Variance.injection,etc.) ft, ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZI THICKNESS MATERIAL
El Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft' ft' i" _
( g/ g PP Y) PP Y( n8
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 s.GROUT
FRI)11 "f0 MATFRIAI. F:111'L:1(:"E11FNT Al 1-HO1)&A51OU\'I
❑Irrigation 0 ft. 20 ft• Bentonite ~Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
[Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL Eft P1.1('EA7 ENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM ' TO DESCRIPTION(color,hardness.wit/nick type.grain sire.etc.)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 88 ft. OVER BURDEN
11-13-2023 88 ft. 605 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Jo Ann MacWilliam Living Trust .
ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. NU
269 Goughes Branch Road Leicester, NC 28748 rt ft.
2, 2Q13
Physical Address.City,and Zip St.REMARKS
Buncombe 9700349794
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 ,,it 11-16-2023
Signature of ed ell ntractor Date
6.Is(are)the ora well(s): 2Permanent or ['Temporary
❑'Di P t Y By signing this form,1 hereby certify that the milts)was(were)constructed in accordance
with i5A NCAC 02C.0100 or 15A NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑lies or El No 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#2l 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 INS'l'UC'fIONS
9.Total well depth below land surface:605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f different(example-34200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 80 (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 Iniection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W EI.LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)2 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 _ well construction to the county health department of the county where
constructed
I orm(,\1'-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013