GW1--02980_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: i
Taylor Ray Boger 14:,W l`ERrZONES .v.4 x .: "a : .z?:;r:, P.IV `, '`+.,,V .W v?. r'
FROM TO DESCRIPTION
Well Contractor Name ft. ft. J
4614-A ft. ft. i
NC Well Contractor Certification Number 15 OUfERC*,SING'(for iritilti-casi3d itiells):OR:LI,NER(if.s pplieable) s
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 73 ft• 6.25 i"• #21 PVC
Company Name '316ANNER'CASIIL'G OR TUBING''(€cothei•iiri dosed-loop)„ „ ; �,,,... ;_,
WEL2023-00493 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. . ; in.
List all applicable well permits(i.e.County,Stale,Variance.injection,etc.) ft, ft. in.
31 Well Use(check well use): '17 S:CRECN.g :>.,> ;;:<<.t'>. .V ', a.� ti'Alit'*'',..E6Ut
Water Supply Well: FROM TO DIAMETER • SLOT SIZE THICKNESS MATERIAL
•
['Agricultural ❑Municipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) z18"GROLJTA ':,;. „ , ks,,;; r, . r
FROM TO MATERIAL EMPL4(:ENIENT METHOD 8 AMOUNT
❑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 49-MtiND/GRTYEL PAVKlif appcabli l 'e) . ' .„'' ..00. D '.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ['Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft,
❑Experimental Technology ❑Subsidence Control 470<DRILLiNG>LOG"(attachadditionalihebliif iiecessary) e x y ,, 1a 3 =.".
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrack type,grain size.etc►
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 73 ft. OVER BURDEN
3-20-2024 73 ft• 205 ft• ;:GR J TEt --N
4.Date Well(s)Completed: Well 1D# ft. ft, y'", ice- ..47 i.,::;.i, V t r,j i
5a.Well Location: ft, ft.
Loren Lusk • MAY 1 62024
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. hir sr-R 't'r• r'r'K>t-F" ^ '✓nt
ir.
32 Garland Ball Drive Alexander, NC ,, ° o3
ft. ft.
Physical Address.City,and Zip 52VRENIARIMQ:lZl;'P.Mr- lga4VPZP.11i2.:':4IT-AlaAVZ,;.W.VaianWrA
Buncombe 972129045100000 WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: .
(if well field,one Ialflong is sufficient)
N w Y 3-21-2024
Signature of ted ell ntractor Date
6.Is(arc)the well(s): ®Permanent or DTemporary 13y signing this form,I hereby certify this the me11(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or EoNo copy of this record has been provided to the well owner.
If this is a repair,fill out known 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
submit one form. SUBMITTAL INSTUC'I'IONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ff.different(example-3@200'and 2®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: IIn,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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: RIG 24c.F_or 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013