GW1--02984_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: '
Taylor Ray Boger 14.tti:ATER24h'NE$ i << .:>
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. d 1
NC Well Contractor Certification Number :15::OUTERC:ASING(for molt,-cased•''iells)'OR L1sNIR(ifap licatile):
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 46 ft• 6.25 in• #21 Pvc
Company Name fort`NEIECASI1SOORVLIBING(M)tiiartniiLetosed=loaf)
20n�—o0508 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L 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.=yCRE>:N,.;; . .,,
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS E.SS MATERIAL
ft. ft in..
❑Agricultural ❑Municipal'Public
R. ft. in.
• ❑Geothermal Heatin Coolin Supply) EResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18::GROUTs _.:. '.. ...-. �t'.`,. i_.'<
FROM TO M,TEWAL &MPLIC:EMETMETtiOD& MOtI\f
❑lrrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovep, ft. H• Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .1.4.:S'AND/GRAVR1,PACK(tf applicably) ___ x.._ . . ... ._
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It
•
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
2t)DRiLLING:LOG(attachadditiiitin obeets:iffreecsarvf ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 46 ft• OVER BURDEN
02-23-2024 46 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# • ft. ft. jn ,a T..,,
5a.Well Location: ft, ft. a.� .t,,;r t.Y,is tP J.=.,
R&S Investments, LLC ft. ft. ' MAY 1 •, 2024
Facility/Owner Name Facility iD#(if applicable) ft. ft.
Lot 39, Indian Paintbrush ft. R. n,'pgra,M: �'� '
Physical Address,City,and Zip °' r'r'
Buncombe 972126142'800000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/tong is sufficient)
N w : 42023te
6.1s are thewel s: ©Permanent or ❑Ten orary
( ) u) P - 8y signing this farm,I hereby certi,{y that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Hell Constntction 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 knonrr well construction information and explain the nature of the
repair under 1421 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
S.Number of wells constructed: 1 construction details. You may also,attach additional pages if necessary.
For multiple injection or non-water supply yells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (fL) 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 2@100') construction to the following: j
1
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 ONLYI 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp ) 6 RIG 24c.For Water Supply&Injectibn'Wells:
13a.Yield m Method of test: ,
PILLS 30 Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 • North Carolina Department of Environment and Natural Resources—Division of Wate•Resources Revised August 2013