GW1--07525_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 tS.OUTER CASING(for multi-rased wells)OR LINER(if applicable)
FROM l'O DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 53 ft. 6.25 in. #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
25
20n��oO2nC FROM f0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L ft ft. la
List all applicable melt permits(i.e.County,State,Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM Tt) DI,%ME'1 FR -SLOT Slit THICKNESS M.1TERR!.
Agricultural ❑Municipal/Public ft. ft. in.
❑
DGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MAlERIAI. EMPLACEMENT NIF.THO11&AMOUNT
Okrigation 0
Non-Water Supply Well: It 20 II. Bentonite Pumped
❑Monitoring DRecovery rt. ft. _ Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Bather
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 53 ft. OVER BURDEN
10-5-2023 53 ft. 705 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Leicester Ridge Holdings ft. ft. A'!)V 2 0 ZO23
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Temujin Drive The Ridge Lot 21A Leicester, NC 28748 ft ft. -
Physical Address,City,and Zip 21.REMARKS -
Buncombe
C'oanty 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 ,It 1 1-15-2023
Signature of ed ell ntractor Date
6.1s(are)the walls): li3Permanent or ❑Temporary By signing this form,I hereby certify that the srll(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C..0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or LINO 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: 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: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3tiu 200'and 2@100') construction to the following:
10.Static water level below top of casing: 140 (ft.) Division of Water Resources,Information Processing Unit,
If miter level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ii.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
I 3a.Yield(gpm) 1 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: 35 well construction to the county health department of the county where
constructed.
I orm CIW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013