GW1--01129_Well Construction - GW1_20240216

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Taylor Ray Boger gii4AVATER ON S W M Mi, M PMC
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ' ft. I
IS`OIITERCASING(for ruultt-caseii 4`ells)OR IANER(ifiiiiiicable)11�'*"': �
NC Well Contractor Certification Number FROM TO DI AMETERI ' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it 52 it 6.25 tin• #21 l PVC
Company Name 41"b"I1VlVERUSING;IDIt1 BING:(lie'other•mttt eloied-Iifap0 `'` 'M,„,r'kr"
DCH-001 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. 1 in.
3.Well Use(check well use): OnSCREENWAAW ',• ;.MEM,WM-.404,7eMtgAt'a,:x.M.W.KIK2SRat
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. 1O
❑Industrial/Commercial ❑Residential Water Supply(shared) 148'GROiI1 *-V ' * "" tUM ma's'1� ,
FROM TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft Cap Top with Bentonite Chips
Injection Well: • ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation f 19:Si Nt)fGlfil'VEL Pry(?I:;,(if<a"liplie lile)*Melfa j,e4, � ',XSION
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater_Drainage ft. •
ft.
❑Experimental Technology ❑Subsidence Control
?'l20snR1 L1NGEO -(attaclt'addrtmnnril slteels if,neeecsar ' AM
❑Geothermal(Closed Loop) ❑Tracerhardness.s ,� �
FROM TO � DESCRIPTION(color, suiUmdc type,gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 52 ft. OVER BURDEN
1-29-2024 52 ft. 365 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. R.
5a.Well Location: it. ft.
James Giers&Sharon Giers ft ft. i�
Facility/Owner Name Facility iD#(if applicable) - 4 �t
It. ft. Ft5 1 C 2024
Eclipse Estates Waynesville, NC 28786 ft. ft.
Physical Address.City,and Zip 2114R8MARKSVA'— r ,, 7:AU' -z- -fit � "
i �� c r4�• a '"���ff�
Haywood 8635-93-6078 Well was self certified D Oja
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient) I
`,lt I N 1-31-2024
Signature of ed ell ntractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that the well(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: ❑Yes or allo copy of this record has been provided to the well owner.
if this is a repair fill out knoizi 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: 365 (ft,) 24a. For All Wells: Submit this,;form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3r@a 200'and 2@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 Iniection Wells ONLY: ln 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
(gpm) RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
I36.Disinfection type: Amount: 35 well construction to the county heAlth department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013