GW1--02986_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 `5,1.4 WATER;ZONE.3. , `a ., ,n .a°:' , iat v. . ;', ,, ._
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. i
NC Well Contractor Certification Number 15 OI.TER'GASING(focrmultr-cased;iti'CIIs);ORliINER'(i'iitppLcable)'%ikw? I .r.,+' ="s
FROM TO DIAMETER! 111ICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f• 62 ft 6.25 #21 PVC
Company Name '011$INER CASiNG.OR:TUIIING(henther"maLcloied-toop),s.` W z`x:
WEL2023-00307 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well permits(i.e.County,State,Variance.injection,etc.)
H. ft. 'in.
3.Well Use(check well use): 17 SCRELI A 1 n� .s. `rAM ' ,. +t,-a. ^..,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public .
❑Geothermal Heatin Coolin Supply) OResidential Water Supply ft fL in.
( €✓ g PPY) PPY
❑industriaUCommerciai ❑Residential Water Supply(shared) 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 Chip
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation A't9 SANDtGRi1'1?Ettrxcx iiiiiilteaNle) ,. , ;; ," W,i
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRiLL'INGz1 OG(attach:additional she'etsaf aecessat^); ' Y x 5' i k;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size.etc.)
❑Geothermal(Beating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 62 ft. OVER BURDEN
3-15-2024 62 ft 585 ft. GRANITE
4.Date Well(s)Completed: Well ID# ,h ,.__,
ft. rt. tj k.s a.� ''V r' W.
5a.Well Location: G ~� r "
ft. ft.
DARYL KEITH CARSON ft. it. MAY 2024
Facility/Owner Name Facility iD#(if applicable) ft, ft. : "r '�; z �.;-
30 PINE RIDGE ROAD ASHEVILLE, NC 28805 irff,Nir.v "tea""t"`"k
ft. ft. I D"`'tilc000
Physical Address.City,and Zip 2IVREi1tARKS 4 .: ems it Nx Zt zr `. Minn,. <;
Buncombe 96698228'42 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 latilong is sufficient)
_- N W 1 .. 3-19-2024
Signature of ed ell C ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify Mtn the we/l(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or Lid NCAC 02C..0200 nu 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 knowai well construction information and explain the nature of the
repair under 42i reran(,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: 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. o SUBMITTAL INS'I•UCTIONS
9.Total well depth below land surface: 585 (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 2 i/l00') construction to the following:
10.Static water level below top of casing: 1 80 (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:1 in addition to sending the fonn 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
i
13a.Yield(gpm) RIG 24c.For Water Supply&Injection Wells:
m 7 Method of test:
PILLS Also submit one copy of this form, 'within 30 days of completion of
13b.Disinfection type: Amount: 35 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