GW1--01180_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger lagW TER ONE �
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. '
154OUTRRVASING(forsmaltkiied:ts`'elli)l?R BINEretifiti"Waite)e} ,
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 FL 93 ft. 6.25 :in. #21 PVC
Company Name
16Ci1NNE12S1NGt)RTUl3C1vC(cittiuusni)elssed 1i;np), . " �
2021-00303 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. :in
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. ;in.
3.Well Use(check well use): s 1:7.?-SGREEN '34 -u ''`WMTRAMOg
Water Supply Well: FROM TO DIAMETER, ,SLOT SIZE THICKNESS MATERIAL
R. ft. in.,
❑Agricultural ❑Municipal/Public
ft. ft. to
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(sin le) '18'GRGIIIT .., In. '"r` i. �A.
❑TndustriaVCommercial ❑Resideniial Water Supply(shared) ``FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
oirrigation 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 41;9:Si1N11TZ;TtR'1l!E1 EACIt'(tf,'apjtlieibl'e') � ilt
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control x,26:1TI11111LINGii;t GOttaele aiiilrttnnal'iheets.tf hies ail ra*:10
❑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. 93 ft. ', ! OVER BURDEN
10-23-2023 Well ID# 93 ft. 245 ft. . , GRANITE
4.Date Well(s)Completed: ft. ft. •
5a.Well Location: '^ •^ T^s r^^
ft. ft. P'y
JUSTIN ROBINSON ` =a`1-g'ii--r C �
ft. ft.
Facility/Owner Name Facility 11 (if applicable) ft. ft. Fhb ✓7 it L
�Ot
133 ANNABELLE LINN DRIVE FAIRVIEW, NC 28730 ft. ft. 1
r- �,
Physical Address.City,and Zip 21`Rl it1ARKa - A ,,---,. — --4
BUNCOMBE " '""
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N W -1— 11-20-2023
Signature ofid
d ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knotssi well construction information and explain the nature of the
repair under#2l 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:245 (fit.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2C100`) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
((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 fonn 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
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 25 well construction to the county health dl p rrtment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013