GW1--01158_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
' This form can be used for single or multiple wells
I.Well Contractor Information: ,
Taylor Ray Boger �� R '
DESCRIPTION
FROM TO _ _
Well Contractor Name ft. ft. I 1
4614-A ft. ft.
15 (1TER.C:S)NG:(fi cam'Ilc�casGtl= 'ells �7tI:G Efk�(` "plicA1M W
NC Well Contractor Certification Number FROM TO DIAMETER _ THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ff. 74 • ff. 6.25 j '.in' #21 . PVC
Company Name "61 13ME42"( :+j15(wt t 'CIJ 1140(07.ti)tt ';ttant;rl yd4tlo '`N
380473-2 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
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ft. ft. ! in.
3.Well Use(check well use): *tiS(REEN ,; E w e , ,
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. tit.
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) • ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15' •D • "' • � : �:�`. '
FROM TO MATERIAL EMPLACEMENT METHOD&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. i
[Aquifer Recharge ❑Groundwater Remediation • "`t'9 1 AND/Gi0g R,f!otC l.(INilille'ktil+e):-.:'. ,•..:' :Meat
[Aquifer Storage and.Recovery ❑Salinity Barrier FROM TO
TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater.Drainage ft. ft.
['Experimental Technology ❑Subsidence Control
• 20:V.la 3."tlOtB:0'(atti'ell aflaitlirW§4(:e iirhVe:ss PAWI : ,r
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) • 0 It. 74. ft. i OVER BURDEN
11-20-2023 74 ft. 225 ft. ! - GRANITE
4.Date Well(s)Completed: Well ID# •
ft. ft. _
5a.Well Location: ft. ft. .':-:':i.-- � _9'
CLAYTON RAY HENSLEY "�
ft. ft. , 1
Facility/Owner Name Facility ID#(if applicable) ft. ft. FtS I 2024
MOUNTAIN PARK LOT 7 MARS HILL, NC 28754 ft. ft. I tn;or ,:i:n?tc7,: �111 LW
Physical Address,City,and Zip t14 AR1a '',,. MO .� t.''i
MADISON 9748-76-5630 WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(it'well field,one latflong is sufficient) j
N W 11-20-2023
Sign of ed ell Contractor 1 Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary
By signing this form,I hereby certify Nutt the miffs)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrection'Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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: construction details. You may also;attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the stone construction,you can
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3C200'and.4100') construction to the following: 1' `
I ,
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 Injection Wells ONLY:i 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: 4
(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
10 RIG 24c.For Water Supply&Injection Wells:
I3a.Yield(gpm) Method of test:
PILLS Also submit one copy of this form;within 30 days of completion of
136.Disinfection type: Amount 20 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
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