GW1--02979_Well Construction - GW1_20240513

-• r'S WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger m4mvATEwzotaswanxmonow:;:om000w4vv,,,..xa
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. ft. 1
NC Well Contractor Certification Number s'z1,5 OUTERWASIP+1GVtic tnaltt-cased't`s'ellsTOR LIiNER(ifa"ppheatile} a'fi
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 55 ft 6.25 in• #21 PVC
Company Name 167-INNER;C.4STNG:QR TUBING;(cothefmiil'closed-looji)i` ', ->` z
WEL2023-00462 FROM TO 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):
aV.SC1tECNVs;�N¢ ab�s. :-5n.: k,.,V...V.x. A rs
Water Supply Well: FROM TO DIAMETER SLOT SIZE T THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
ft. ft.❑Geothermal(Heatin Coolin Supply) ElResidential Water Supply(single) in.'
l'I GROUT'`,'? z ' ZI :� ' v '",V' . `. . 'e Vr S,r,,t
❑Tndustriab`Commercial ❑Residential Water Supply(shared) FROM TO st rrEtuAL EMPLACEMENT METHOD S AMO1IN'T
❑Irrigation 0 ft* 20 ft• Bentonite Pumped
Non-Water Supply Well: -
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANi1!GRAYELIPAt?K{if appttcaTileM ;': ,O ^; -s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
420 ftItILIING410G,TalfiClitidditiniiiteslieelilitieteitif-WAW,USeri,„Vitgiftt
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 55 ft. ' OVER BURDEN
2-20-2024 55 ft• 605 ft GRANITE
4.Date V4'ell(s)Completed: Well ID# ft. ft. ;;_-� --�
e
5a.Well Location: ft, I. F"�•'i e ' ,r l� tl"�
JONATHAN&AMBER MILLER ft. ft. MAY d �,.
Facility/Owner Name Facility ID#(if applicable) C OLd
ft. ft.
92 JOHN TATE DRIVE FLETCHER, NC 28732 :rf.:;; ; . „—.-• ,, .
ft ft `4 -✓71 i
Physical Address.City,and Zip D Q ' `6's ..
.ziatEn7ARIcs . «MA � A kn oh ,,e � . c
Buncombe 9685090928
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 lY 40, 2-27-2024
Signature of ed ell ntractor Date
6.Is(are)the well(S): [r7 Permanent or ❑'I empOrary By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out kaolin 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:
,I You may use the back of this pagelto 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 INS'1•UCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths if d erent(example-3 t;200'and 1®100') construction to the following: i'
10.Static water level below top of casing: 200 (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:I 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.) I
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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.1)isinfection type: Amount: 35 well construction to the county health department of the county where
constructed. I
11
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water 1+esiurces Revised August 2013
f
1