GW1--02985_Well Construction - GW1_20240513

i
•
WELL CONSTRUCTION RECORD For Internal Use ONLY: 1.
This form can be used for single or multiple wells
I'1.Well Contractor Information:
Taylor Ray Boger a wvrER O:v,s m n . xvw mox .x . ,r
FROM TO DESCRIPTION
Well Contractor Name ft. ft. ' I
4614-A ft. ft. !'
NC Well ContractorCerliticationNumber 15:OUTERC.ISING(foatitiltt-casettiWellWOR INER(rtippliehbtej'� r
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 n. 44 ft 6.25 ; in. #21 l PVC
Company Name 101NIYER:C8SING`OR TUBINC(ge4tb4rroal;'closed]aap) l sw � :` z'
2022-00512 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ,`in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) It. ft. in.
3.Well Use(check well use): t;7 SCREE) OM 4145V .,1 Pa k.aW MMAT'` ,:?; g
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalfPublic ft. ft in.
❑Geothermal Heatin rCoolin Supply) OResidential Water Supply tt. rt. in.
( !'� g PP Y) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) '.t&rGROu'fia : ;�s"` ' ' `,`�,'p ... "'. `,, ""°°
FROM TO MATERIAL EMPLACEMENT METHOD&AMOu NT
❑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 SASH/GitAVEI 1?i1CK'(if,ajipllcatite},;,; ; )m', w-mi
w
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control
20.Al21LL"7NGiti'OOattich:addi rt nunti reds itiiiiesaarv)N `�; .:"%
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 44 R• OVER BURDEN
2-22-2024 44 ft- 205 ft. GRANITE
i.
4.Date Well(s)Completed: Well ID#
ft. ft. 71 `R _
5a.Well Location: ', • -
R&S INVESTMENTS OF WNC ft. ft. I. (�
Facility/Owner Name Facility ID#(if applicable) MAY 1y� 2U24
ft. ft.
ROLLING HILLS OF FRENCH BROAD LOT 53 ALEXANDER,NC
ft. ft. ITiv ,,,-e r'l i) '+7 R. Vt t My
Physical Address.City,and Zip .21;°12.EIti4ARIZS ;ems,9;ua .',`A:'�s)w.' AWN:,44a'n'UvT e7g Y 41
BUNCOMBE 972116758900000
County Parcel Identification No.(PIN) I,
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N yy -C 2-23-2024
Signature of ed ell ntmctor I Date
6.Is(are)the well(s): ®Permanent or ❑'Temporary By signing this forts,I hereby certifi,that the well(,)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction 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,fell out known well construction h formation and explain the nature of the
repair ander#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
S.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 i
submit one form. SUBMITTAL INSTUCTIONS
I
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 i di erent(example-3 00•and 2 a;100' construction to the following: Q
P P .f .O� p e+� C )
10.Static water level below top of casing:40 (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:iI in addition to sending the form to the address in
ROTARY 24a above, also submit a copy off: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) 10 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form I 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I