GW1--01184_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells l i
1.Well Contractor Information:
Taylor Ray Boger ti wamEVZON s ,VAMP ' m - or zm s ,. ,17.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ' ft. I ,I
NC Well Contractor Certification Number • IS tOUTER CASING'(for malb-easedicells)IDR'i 1IVERI'(itTrni licable)Sy , ,
FROM TO DIAMETER! THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft. 6.25 #21 1 PVC
Company Name d1G:rNNER`t'.A"SInO;OR�TUBINC;(geiiiotberinalclosed-loop} "� � ��,1 ',,,�:�;`,��
2023-00273 FROM TO DIAMETER 'THICKNESS MATERIAL2.Well Construction Permit#: ft. ft. I ,in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. 1 I in.
3.Well Use(check well use): `17 SDREENS "` `.,Q. x. NI. y.. . x..W4147 , ra'''M*IiI5
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NATERtAL
❑Agricultural ❑Municipal/Public ft. ft. in•,
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in'
❑Industrial/Commercial ❑Residential Water Supply(shared) t8>`GRt)UT` r�^'''� z ..�;� �; v s, 'KI `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0
ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
DMonitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19`SANti/GR'114,E1 Pf1t'K':(if applicslile)VOIO.>r k:'',,,MaralMigai&Vi
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage R, ft. f
['Experimental Technology ❑Subsidence Control
;20:4DttILtINCIO (atoll adrldiiiiii(ilteetiifn c&ini ) IV ° 41
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soiVrock type,grain size.etc.)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
1-15-2023 60 it 165 ft. GRANITE
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: �u.o 7 ;^ ,�t o S•,...t"
ft. ft. ! ; '0;..... Lis V L- ..+'
April Taylor ft. ft. F tb J 9 ?G74
Facility/Owner Name Facility IDA(if applicable) ft. rt.
Ridgeway Road Candler, NC 28715 ft. ' ft. trtotl:t( .,1 P::;;.,'_K Ji:-v2, Ur;:i
Physical Address,City,and Zip d f`t'lt�
'421 REALARKSV 4-I x: , s*„ a., .t PW.410,4.,,.
Buncombe 8686280754 Well was self certified
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it•wellfield,one lat/long is sufficient) ,
N `,lt 1-19-2024
,h_g %4-611,
Signature of ed ell 24ntractor Date
6.Is(are)the well(s): ©Permanent or ['Temporary By signing this farm,I hereby certi that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or I No copy of this record has been provided to the'well owner.
If this is a repair,fill out know:well construction information and explain the nature of the
repair under 421 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,pi•ovide 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. SUBMI'ITALINSTUCTIONS ,
9.Total well depth below land surface: 1 65 (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 2@100') construction to the following: I
b
10.Static water level below top of casing: + (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i.
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 c
(i.e.auger,rotary,cable,direct push,etc.) ` ''
Division of Water Resources,Undei'groutfd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
(gpm) 30 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.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 Resource's Revised August 2013