GW1--02972_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information: I
Taylor Ray Boger t 14:WATER#Zt),''GSA "'� ru ff a5
FROM TO _ DESCRIPTION
Well Contractor Name ft. ft. I i
4614-A ft. ft.
NC Well Contractor Certification Number
,12S 1UTER&ASING(for%iniiltsased„•ells ORls1NER"(iCappLcaUle) ` I <' r
FROM TO DIAMETER , IIHCKNESS l MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 52 it 6.25 in• #21 PVC
Company Name 416 1NNER`rCOING;.OR<•TI[BANG:( CbRhiirmnl'elosetliltiriji it a xr na ' ',,
DGS-002W 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. in.
3.Well Use(check well use): a=.1,7:SGREE1±tf,�"•-AIM u >r =,PI ' .k,M`?MA IIIV
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
❑Agricultural ❑Municipal/Public ft. ft• in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) I$'GROMMO MAM 11:§ A � `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt• 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft. '
❑AquiferRecharge ❑GroundwaterRemediation II9:SAIYl1`iGRAN.E1,.P,r1C1C'(ffiiiiptleatlo) '` Atalfe , " A
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rt. ft.
DAquifer Test ❑Stormwater.Drainage ft. ft. 1
❑Experimental Technology ❑Subsidence Control
h2 s flRIiL'ISINOJIZG.(nttactiltildittnntil,'slseafsif uecessarl§) !If . w
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,gram size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft. 52 ft. OVER BURDEN
12-20-2023Well ID# 52 ft• 205 ft• ,,,,•GRAN ATE
4.Date Well(s)Completed: ft. ft. V a '
Sa.Well Location: , " ,a� �
It. ft.
MARY YOUNG n• - ft. MAY 1 7. 2024
Facility/Owner Name Facility IDk(if applicable) R. ft. 1 a�..,r ,",. ° ' , um
1901 JOE CARVER ROAD WAYNESVILLE,NC L.v„nc�e £:k.3 l
ft. ft. L'rr�(.J�t h
Physical Address.City,and Zip I JLE fARESN 00. 41,'O t:<EI X74, 1*I;W.MVAI,S'
HAYWOOD 8609-13-0975 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lattlong is sufficient)
N W 12-29-2023
Signature of ed ellntmctor Date
6.Is(are)the well(s): QPermanent or OTemporary By signing this form,I hereby certify that the ue11(s)was(were)constructed in accordance
with ISA 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 ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knonse 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
12-20-2023 24a. For All Wells: Submit this form within 30 days of completion of well
9.7'otal well depth below land surface: (ft.) �, Y P
For multiple wells list all depths iftli erent(example-3@200'and 2 a'100') construction to the following:
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 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.e.auger,rotary,cable,direct push,etc.) I'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i Center,Raleigh,NC 27699-1636
13a.Yield(gpm)20 Method of test: RIG 24c.For Water Supply&Injection Wells:
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-i North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i i