GW1--01130_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1
1.Well Contractor Information:
Taylor Ray Boger %,44 nW TERIO;lESV . 1 xVATR ; K x
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. -
%15reOtITERVCASINC(far`iniltiFengeirtiiiltiTORzL'NERlirinieatite) 4 ^ E,
NC Well Contractor Certification Number FROM TO DIAMETER) THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 138 ft, 6.25 #21 l PVC
Company Name
x16:iINNEWCASIN'6ORWTU)3iNGF(i~eothe intirCti sedaiiiin .,,W4t ; ;.
GJB-184W FROM DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ,in.
List all applicable well permits(Le.Count;State,Variance.Injection,etc.)
ft. ft. ,in.
3.Well Use(check well use): 17 SC1tEENs '. . .e _ME. g", t r
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public H. D. in
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑Industrial/'Commercial ❑Residential Water Supply(shared) i18:•GROLITi Y �� maN .;� s + 'r°
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Weil:
:Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection V1'ell: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 29 5:N15/GRi'IY,EL.Yr\t?[{'t t'applle'ifslel WA',• 24151,V'1 r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rt, ft.
0 Aquifer Test ❑Stormwater.Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
tIOXDRIBEINGTOG.(attnelfiddittiiiiiitilie'efiltifeeiiiiiiiPTIOMIUMAIME
❑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. 138 ft. OVER BURDEN
1-31-2024 138 ft- 305 ft. , • GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. �� ; ` - G
Mary& Robert Queen ft. ft. y
Facility/Owner Name Facility lD#(if applicable) ft. ft. FL 1 C 2024
Reed Cove Waynesville, NC 28786 ft. ft. Isitorrn ri?frI0 ,;t,_ Un
Physical Address.City,and Zip ;21I REn1AiRKS `,e x4P'°MMA4:04 t+ r:O/Z , i
Haywood 8635-71-8702 Well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one iaulong is sufficient)
N N, 2-2-2024
Signature of led ell ntra ' Date
6.Is(arc)the well(s): ©Permanent or ❑Temporary 8y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or ISA MCAC 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 521 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
S.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 if different(example-3C200'and 2Ca 100') construction to the following:
10.Static water level below top of casing:40 (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 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 7 Method of test: RIG
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