GW1--07524_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.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 wells)OR LLNER(If applicable)
FROM It) DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 31 ft• 6.25 in• #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
We12022-00582 FROM TO DIAMETER
in. THICKNESS MATERIAL
ft. ft.
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 SIZE THICKNESS MATERIAL...
Agricultural ❑MunicipaVPublic ft. ft. in.
❑
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply it. ft. in.
( 8/ 8 PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM "f0 MATERIAL FMI'L.ACEME'T METH01)&,AMOUNT
❑ltrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well: ft. rt. Cap Top with Bentonite Chip;
❑Monitoring ❑Recovery _
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicably)
FROM TO MATERIAL. E)1 PLA('EM F:N1 MI:1110D
❑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)
❑Geothermal(Closed Loop) ❑Tracer FROM 1'O DESCRIPTION(color.hardness.soiVrock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 31 ft- OVER BURDEN
11-9-2023 31 ft• 385 ft• GRANITE
4.Date Well(s)Completed: ---- -Well 111# ft. ft.
Sa.Well Location:
ft. ft.
Franklin Morgan ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
67 Potato Branch Leicester, NC 28748
ft. ft. ^'i)179r1 ..�„
Physical Address.City,and Zip 21,REMARKS
Buncombe 86896954190000 Well was SELF-CERTIFED
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, � 11-15-2023
Signature of ed ell ntractor ik Date
6.Is(are)the well(s): BPermanent or ❑'Cemporary By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo 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#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 can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2iu;100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:20 (ft.)
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 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of teat: 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: 35 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