GW1--03494_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM TO DESCRIP11ON
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LLNER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 70 ft 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WEL2023-00437 FROMTODIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ue!!permits(cc.County,State,Variance,Injection,etc.) ,1
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MAIT:RIAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
fi. ft. in.
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1g.GROUT
FROM TO MATERIAL EMPLACEMENT MF'.11101)&.AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well: ft. R. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19.SANDtGRAVEL PACK(if applicable) g x F;.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑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• 70 ft. OVER BURDEN
4-05-2024 70 ft- 225 ft• GRANITE
4.Date Well(s)Completed: --Well 1D#
c _
Sa.Well Location: It. ft. R�r Li �E ILA
KERRY LENGYEL ft. ft. JUN 1 2 2024
Facility/OwnerName Facility ID#(if applicable) ft ft.
25 STONE RIDGE DRIVE CANDLER, NC 28715 rt. ft. ►rt,o-.:-4•p:'r?'" •.' -'9 UPI
Physical Address,City,and Zip )71`L' C to
21.REMARKS
Buncombe 8697443599 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latflong is sufficient)
N W 4-16-2024
Signature of ed el tractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15.4 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 0 No 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 INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(different(example-3@200'200'and 2@r;100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:40 (ft.)
If writer 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 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)20 Method of test: --
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
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013