GW1--01174_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
1.Well Contractor Information:
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Taylor Ray Boger 144WAT,t R ONEs� g.. , ; ?';
FROM TO DESCRIPTION
Well Contractor Name
fit, ft.
4614—A ft. ft. I
*15AIUTEI ASING,(foe m6ltt-cased:hells)tORTINERi tf i'liCab )`te
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 79 ft• 6.25 I in• #21 PVC
Company Name lt5ANNERCASING.:URrTUBING,(eotliennal'.ciosed-loap), ` x,.." `
2023-00378 FROM TO DIAMETER'. THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft. ft. - in. -
3.Well Use(check well use): ,' SCREElslw; .,M. , M.S*4100M . ' ._.t--' f :VA
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
ft. fL in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(sin le)
WGROUT V0, :fw .? f``:a ? _ i"s ,XX K 1.446 ' =
❑Industrial/Commercial ❑Residential Water Supply(shared) 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. l;
❑Aquifer Recharge ❑Groundwater Remediation 1:19:SANDIGRANEL:PACK of appliiat te). " I'A?V.. .: ` xk.s a <e_
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
0 Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control "e ,
20:>DRIL`LING'lit)C,(attadiailditinnnl>sbets,eifnec`ecsar}), r:,i , r>,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soi crock type.grain size,etc.)
•
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 79 ft. OVER BURDEN
11-22-2023Well ID# 79 ft• 305 rt. 1 GRANITE
4.Date Well(s)Completed: ft. ft.
Sa.Well Location: ft. ft. 1, 7,
TLF Woodlands LLC '" � : 1� ""
ft. ft. « ,y ;
Facility/Owner Name Facility ID#(if applicable)
ft. ft.2214 Sand Branch Road Old Fort, NC 28762 FEB 1024
ft, ft.
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Physical Address.City,and Zip Zt<REN•IARKS,OS'. 1F1=MO, #qt.lr" E*,;TI'i v^ rrt<tip,)t.
Buncombe 062619729100000 Giv'O OG W
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N
W t �..
12-8-2023
signature of ed ell nractor Date
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6.Is(are)the well(s): ©Permanent or OTemporary 8y signing this form,1 hereby certify that ihe,well(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 ENo copy of this record has been provided to the well owner.
If this is a repair,fill out knossn well construction information and explain the nature of the
repair under N21 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 INS'I'UC'I'IONS
9.Total well depth below land surface: 305 (fit) 24a. For All Wells: Submit this formwithin 30 days of completion ofwell
For multiple wells list all depths if different(example-3@200'and 2 a@100`) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resom cgs;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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,Raleigh,NC 27699-1636
30 RIG 24c,For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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)di partment 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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