GW1--01188_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 wI•t$IMATER;zONES.< '., ° E w..' . arv. _.
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. ft.
NC Well Contractor Certification Number MVOUTERVASINatfoilitiilti4CaSedWeIWORIINERlifriji—liabteMW511ZZion
FROM TO DIAMETER 11 THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 107 ft. 6.25 1: r!r• #21 1 PVC
Company Name .16-INNER:CASINt"s'OR T I61NG($eotherioitl closed-#otip)M.W4 `" w 4W
2021-0320 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft, ft. I;in.
3.Well Use(check well use): 17 SCREEN. . "` ' s �z ) ` M,!. ' x t..me
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIIICICNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft in.
ft. ft. fn.❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑industrial!Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD'Si AMOUNT
❑Irrigation 0 ft' 20 ft- Bentonite' Pumped
Non-Water Supply Well: ft. ft. I Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery I
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 'v19,;4ANDlGRAVEi,Pii(;K(if-applicabte)a ` .iT ,F ,:4 „ Z ` '°.:711
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIA EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -- -ft. ft.
❑Experimental Technology ❑Subsidence Control
TK26.DRiELINGIGafattaelifaddrttnna'7`sheetsdf necessar PW - w, Z
❑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• 107 1t• • OVER BURDEN
12-22-2023 107 ft• 205 ft. j GRANITE
•
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. o ^'>,r^9 err,,,-.
Clay Plemmons ft. ft. ��' �� L
Facility/Owner Name Facility ID#(if applicable) ft. ft. I, I tb 1 9 2024
Big Cove Road Candler, NC 28715 ft. ft.
Physical Address.City,and Zip 11 tREIVIARKS`s ``..V: +WW a' . 141 y,; s .e 's it.;`'
Buncombe 8697088143 Well was!self certifiecP C.et
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient)
N W
16 12-26-2023
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or OTemporary
By signing this form,I hereby certibi that the ur1/(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200!Veil Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I INo copy of this record has been provided to the well owner.
If this is a repair,fill out knoust 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 tolpiovide additional well site details or well
8.Number of hells 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 I
.subunit one form. SUBMITTAL INSTUCTIONS I, I
9.Total well depth below land surface: 205 (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,
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 form to the address in
ROTARY 24a above, also submit a copy of this I 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,IRaleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form l ithin 30 days of completion of
13b.Disinfection type: Amount 20 well construction to the county healtlj 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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