GW1--02988_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 L44wATERzoNts , w# m K ;.., , ;: : =o,„;
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4614-A ft. ft.
NC WellConuactorCeriificationNumber AIS ouTERCASING;(fo'rmultt-cblciYkti'ells)oRANER(iP hull uble')=
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 ft. 6.25 ' in. #21 Pvc
Company Name AldANNEWCAStNGORMTHINGTOWiiiitinveitiiVillititiftWOM0;=1,006W4
WEL-2023-00428 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ; in.
List all applicable well permits(i.e.Counry;Stale.Variance,Injection,etc.)
ft, ft. in.
3.Well Use(check well use): ar17 SeREENs N: ,, 40 .. . , A'.1' S :?`V r Mi
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public ,
ft. ft. in.
❑Geothermal(hleating/Coolin Supply) OResidential Water Supply(sin le)
ei
❑Tndustrial/Commercial ❑Residential Water Supply(shared) ti`18 OUT�� ,:',r,° �' 't"`W °1~ ' 1''t' `"� '
FROM TO 6L1'fERL1L EMPLACEMENT METHOD&AMOUN'T
❑irrigation 0 it- 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 19,591!,'D/GRJ1Y.t L;PACCi tU:applisaGle'):Z. : AAM. ttc aA;:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Storrnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
1t20:DRILL INGI 0G,(attach:addttionalNbeefs•if;uececsa*3'}., eR. ls
❑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 ft• 65 R• i OVER BURDEN
03-27-24 65 1t 405 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft, ft. Ir ,.., d•-
,
5a.'Well Location: ft. ft. .
ALTAMOUNT CONST. ft. ft. MAY 13 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
• ITI`u :i:i:Fi t� N:;Ra LW;
.
478 JUPITER RD WEAVERVILLE, NC ,t .
. ft. ft. D` C22:1 jL`,`
Physical Address.City,and Zip
BUNCOMBE 9734984721 2PRENIAturs. ,s., .... Oke. � a � .
THIS 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 lat/long is sufficient)
N W 04-22-2024
Signature of led ell ntractor Date
6.Is(arc)the well(s): fr7Permanent or ❑Cemporary By signing this faun,I hereby certify that the ue/l(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 DNo 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 1121 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.
1.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMIT IAL INS'1'UC'I'IONS '
9.'I'otal well depth below land surface:405 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qj200'and 1@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:, 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: 1.
(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
(gP 24c.For Water Supply&Injection Wells:) 7 RIG
m I3a.Yield Method of test:PILLS C Also submit one copy.of this form, jwithin 30 days of completion of
13b.Disinfection type: Amount 1 tJ well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Re ources Revised August 2013