GW1--01191_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD 1
For Internal Use ONLY: 1
This form can be used for single or multiple wells
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1.Well Contractor Information:
Taylor Ray Boger
I4 NV,r1TF,R<ZONESTAAMWA,'VAISS° i � TA t �- .z<.-,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I I
NC Well Contractor Certification Number IS:OIJ'f'ERCCASING'(for nitiltt caged n'ells);UR INER)if.ipQLcable)'; •t. -war
FROM TO DIAMETER 1 THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC 1-1 It. 93 It 6.25 j I"• #21 PVC
Company Name 16 INNERIGASiNG;ORxTUBINGWofher?n'itl'clos"edaoop) =09KiW i ate,T
2021-00127 FROM DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. II, in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) _
ft ft i in.
3.Well Use(check well use): 17ISGREIiN 7., .li V;.::N,I a y ,z:„ jM_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROtIT1 °`' - `' "• `••v "'
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 Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .f19lUNI 1GRAVEL't!A'(:tC 4 CapiilicaGl'e) .n,MT Z :i : , ,. -
FROM TO MATERIAL . EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft ft.
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❑Aquifer Test ❑Stormwater.Drainage It. ft.
['Experimental Technology ❑Subsidence Control
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Il20DRtLLL1NGill0 (attachaddrftnsarl'sheetsltiiiiiiii ))1 .< lNN,.t.,t.
❑Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,hardness,soil/reek type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 93 ft. OVER BURDEN
12-22-2023!Yell ID# 93 ft. 365 ft• j GRANITE
4.Date Well(s)Completed: ft. ft. 7 • .. r PI,:-.,
5a.Well Location: ft. ft. ..k f.aVa
Darrell Craig ft. ft. I-to 1 9 20Z4
Facility/Owner Name • Facility ID#(if applicable) ft. ft.
•
Brooks Cove Road Candler, NC 28715 ut,.�::
ft. ft ttlwti7 {c,l n +w
01
Physical Address.City,and Zip 121=REN'tAR(Cs e� o , i AT4 YM,z 4,''DANO0 ?a •
Buncombe 9608245942 Well Was Self Certified
County Parcel Identification No.(PIN) 1 '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient) 1
N ,,lr �' {� �.; 12-29-2023
Signature of ed elltractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 1
By signing this form,1 hereby certify that the ue1/(s)was(were)constructed in accordance
with 15.4 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 BNo copy of this record has been provided to the well owner.
it
((this is a repair,fill out known 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 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.'l'otal well depth below land surface: 365 (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(fa 100') construction to the following: 1
10.Static water level below top of'casing: 30 (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 form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centr,IRaleigh,NC 27699-1636
(gpm) 20 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test
PILLS Also submit one copy of this form t ithin 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Reso i ces Revised August 2013