GW1--01181_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Taylor Ray Boger f.ovATEwz >;s.: ; - . `- -- -
FROM _ TO DESCRIPTION
Well Contractor Name ft, ft•
4614-A ft. ft. 1 1
NC Well Contractor Certification Number 15 UUTERzGl1S11YG(foi:tnglticasrelltWellsjK)R3:INERQIfa Make) ? ;4
CLYDE SAWYERS & SON WELL & PUMP INC FROM ft. 60 ft. 6D2IA5 ET1.R in. 1HICK21SS MATERIAL
#21 PVC
Company Name "I'ti:(MINER CASING;OR;T[J$I}+1G;(gepthermaticlosed»!on'jt) z a WrOMO
2022-0022Q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C7 ft. ft. I in.
i,
List all applicable well permits(i.e.Counq;State,1"ar•iance.Injection,etc.) ft ft in.
3.Well Use(check well use): 7."ApREEN ,AM.,. ', A -` , ' o
w.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) k ft. '"'
❑Industrial/Commercial ❑Residential Water Supply(shared) i18GI tallT TO ?;� ,,MMI ' '~ ,, ,
MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigation 0 ft. ft.
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑Croundwater Remediation
49 WAND/RAV,EC,P:C(3glil illilkiEs)c} 4rke r 4 , ,
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. 1
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control '
l6ADRIIILING,10a(ittifel eaddt6ntlal gbeets iraftessar'y)
El Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 60 ft. OVER BURDEN
11-28-2023 60 ft- 405 ft. j GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. '
5a.Well Location: ft, ft. - --
Jos & Karen Baleno `` a.�
ft. ft. "' 1`'�....', Qy
Facility/Owner Name Facility ID#(if applicable). ft, ft. i-t b 1 9*2024
48 Bird Creek Estate Road Black Mtn, NC 28711 ft. ft
Physical Address.City,and Zip Z1:Itl;htARIfS :' ''�'?z�r r %�\ � ' -.e .,kx m`' UM
Buncombe 063667325000000 . Well was self certified :J .
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient) j
N w 11-29-2023
Signature of ed ell ntractor Date
6.Is(are)the well(s): ❑Permanent or ❑'Cemporary By signing this form,I hereby certify that the ur/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Sttmdardr and that a
7.Is this a repair to an existing well: DYes or ENo copy of this record has been provided to the',reel/owner.
If this is a repair,fill out knon7t 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:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 241100') 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 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 '
(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
13a.Yield(gpm) 15 Method of test. RIG 24c.For Water Supply&Injection Wells:
PILLS 35 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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