GW1--02978_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: '
Taylor Ray Boger .1 t.1WlTER•Zo4VCS w y.., <`.x: % g g; N��,.� wz.y., tf?.
FROM TO DESCRIPTIONI
Well Contractor Name ft. ft. I 1
4614-A ft. ft. '
NC Well Contractor Certification Number `15 OIITERCASING(fo'r'in6lti4ffied n'ells);ORLL'VERB(iffijilicable): � ?s `:i
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1- ft 122 ft. 6.25 :in. #21 Pvc
Company Name 416 INNER'CASING'OR�TUBING;(geothei•inid ilif edaotifi)i VM�, ,'>
WEL2023-00292 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well permits(i.e.County,State.Variance.Injection,etc.) ft, ft. in.
3.Well Use(check well use): ,17 SGREENA I r sue. '; `";g.F.`. �,, 1Ag. ,; T s
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
f. IL in.
❑Geotherma((Heating/Cooling Supply) Residential Water Supply(sin le)Dindustrial/Commercial ❑Residential Water Supply(shared) ''1$'GTt011T.s '- �' '`' � ' w'_ .' t K"'#"'`"'k` """
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 Chipl
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ;19 SAANl/GRAVEL Mt'.K?(if:aphlleal le)it`" � +0 ,',';:a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control n
�26:;i1RILLINCILDOatticl%"ndditinna"Isbcetrif ececsIW it e t
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness soiVrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 122 ft• OVER BURDEN
3-4-2024 122 ft• 705 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. _
,. I`" , ,7-", vt. a_
'
5a.Well Location: it. ft. : ti.;,,e.k,., .tom
DANIEL E. GRINDSTAFF ft ft MAY Name Facility MO(if applicable) MAY 1 2024
ft. ft.
999 OLD NC 20 LEICESTER, NC 28748 ft• ft. 11-,:C.”X :0r. ;3-,7:s. y;,� )
slIN
Physical Address,City,and Zip 1,411AREMARKS y..-: 3AAAVAM W:a4 ViO *Ir
Buncombe 971166852
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
Orwell field,one tat/long is sufficient)
N `l, 3-14-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): 0 Permanent or ❑'Cemporary By signing this form,I hereby certify that the well(,)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 ENo copy of this record has been provided to the well owner.
If this is a repair,fill out knoure well construction information and explain the nature of the
repair under 02/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: 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 INSTUC'1'IONS
9.'I'otal well depth below land surface: 705 (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 2Ga 100`) construction to the following:
10.Static water level below top of casing: 50 (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:j 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.)
Division of Water Resources,Underground Lijection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp 24c.For Water Supply&Injection Wells:
) 15 m 13a.Yield Method of test: RIG
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the couunty health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water)tesources Revised August 2013