GW1--03496_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger .','. �1 s -_.FROM TO DESCRIPTION
Well Contractor Name ft ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 95 ft• 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) ,
WP23-023 FRO
2. THICKNESS MATERIAL2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft, ft. in. -3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIFT THICKNESS MATERL11.--_
❑Agricultural ❑Municipal/Public R• ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) tit. ft. in.
( � g PP Y) PP Y g
❑Industrial.%Commercial ❑Residential Water Supply(shared) 18.GItOt1T
FROM TO Ais AERIAL F.MPI,%CEMENT METHOD&,AMOUNT
❑irrigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
aMonitoring ❑Re(xwery ft. _ ft. Cap Top with Bentonite Chipt
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 10.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. tit.
❑Aquifer Test ❑Stormwater Drainage - '
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attack additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(colic.hardness.soiVrock type.grain size,etc.)
❑Geothermal(IHeating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. OVER BURDEN
4.Date Well(s)Completed: 5-17-2024 Well tD# 95 ft 505 ft. GRANITE
ft. ft. f _ __ -.
Sa.Well Location: R. ft. tr" Lr L.. , `r E id
2020 BUILDERS LLC ft. ft. JUN 1 2 2024
Facility/Owner Name Facility 1D4(if applicable) ft. R•
BUENA VISTA DRIVE BREVARD, NC 28712 rt. rt. lnf✓.xx.i '' '-^^4rq':1 J,r,
Physical Address.City,and Zip _-_ D'f.(1.
' .�
II.REMARKS
TRANSYLVANIA 8585-13-4986-000 THIS 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 lat/long is sufficient)
N Mtn ` 5/22/2024
Signature of ed ell ntractor Date
6.1s(are)the well(s): ©Permanent or ❑Temporary
By signing this farm,I hereby certify that the medic)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1E1 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 li2I 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: constnuction 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: 505 (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 2441001 construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 140 (ft.)
If rater 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
13a.Yield(gpm) 505 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 3.5 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