GW1--01194_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger %4gWATER<ZONRS,s:'" IMMI ` .Mir .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I
NC Well Contractor Certification Number /Is OIITER.eASING(foie:maltt-cased itells);OWLlNERAiriipphcable) t.'`.;_..
FROM TO DIAMETER:{ THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. +28 ft. 6.25 i in. #21 l PVC '
Company Name 16ANNER:Ci1SING'OR T IBiNCsl cotEierroat?ct`ased-Ieap)=2 n'" ;'>^ ...;k^s?`` ;+
2022-00507 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(Le.Count,State.Variance.Injection,etc.) fr ft. in
3.Well Use(check well use): 17?SCREENN<.mV i MA' ,A V,". w" . ?s< kgr, ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. , !
fr' ft. in.
DGeothermal(Heating/Cooling Supply) ElResidential Water Supply(sin le) '
vz18:G`It(lI1W4° '1 44.v�s, 4s.4V a;+ ''''' x.,+" ',t_ a:;*,
❑TndusfrialfCOmnlercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite' Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery it. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation A-9"S'ANDZGRXVELOAURIiratittlieabfilfMAIMPWAWAVMAMMOV
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fr, ft. +
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
.20:{DRlLLiNG<LOG.(attael'additional's"beefsit'.uec"ecsar})M AiU
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soiVraek type.gram size.eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 28 ft. ; , OVER BURDEN
12-13-2023 28 ft. 325 ft. . . GRANITE
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location: ft. ft. i,
R&S INVESTMENTS OF WNC k"
ft. rt. t"I.�... e u"a r te 0
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ROLLING HILLS-OF FRENCH BROAD LOT 38 ALEXANDER,NC ft. ft. ' �� i 9 [U14
Physical Address.City,and Zip ., 4';x i' �
`21 RE1GtAR1GS�'`v, , ,'� I ,�c ��.",„ ��,
BUNCOMBE 972126041000000 1"" "�```it '�A;vt►
D,fwt, fG
County Parcel identification No.(PIN)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w -1-' L 12-18-2023
Signature of red ell ntractor Date
6.Is(are)the well(s): t lPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 154 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,nell owner.
If this is a repair,fill out knowst 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 i
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this feirm 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:
10.Static water level below top of casing 20 (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:
lie.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
it
I3a.Yield(gpm) 30 RIG 24c.For Water Supply&Injection Wells:
Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount 25 well construction to the county health department of the county where
constructed. J
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resourci s Revised August 2013