GW1--03538_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 '1-O DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)O ' iii s??(If applicable)
FROM TO DE1h1E1E11 THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it 85 ft• 6.25 in. #21 PVC
Company Name lb.INNER CASING OR TUBING(geothermal closed-loop)
2024-00071 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt, ft. in.
List all applicable well permits(i.e.County,State.Variance.Injection,etc.) R ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: _IRON' To_ DI-1MEIE.R _J1.OTS17F. IIII(C KNESS MVIERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public _
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) H. ft. in.
( P>t 8 PP Y) PP Y rag
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FRUM fo MAT F.RIA1. EMPLACEMENT MET HOD&AMOIFNT
CI Irrigation 0 ft. 85 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. fit Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM It) ML1"rFRIAL_ FMPE,ICFM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ` It.
❑Aquifer Test ❑Stormwater Drainage
-
ft. ft.
❑Experimental Technology ❑Subsidence Control
—
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I-TO DESCRIPTION(color,hardness.toil/rock type.grain size.etc.)
I_IGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1h ft. OVER BURDEN
3-25-2024 85 fit• 205 fit• GRANITE
4.Date Well(s)Completed: —Well ID# ft. ft.
Sa Well Location: ft. ft. 17: ``e L.. ,v E Li
Steven Hildebran ft. ft.
Facility/Owner Name Facility lDd(if applicable) JUN 1 2 2024
ft. ft.
117 Legacy Trail Drive Leicester, NC 28748 ft. ft. Irk,.;:-.-c,7il :►'.'"- 4-
Physical Address,City,and Zip 21.REMARKS Ws Cy t-.i,i
Buncombe 97014155000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IatAong is sufficient)
N W 3-28-2024
Signature of ed ell ntractor Date
6.Is(are)the welt(s): 10 Permanent or ❑Temporary B3,signing this form,I hereby certify that the wells)was(were)constructed in accordance
with i5.4 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 El 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#2I 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. n G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3€4200'and 2 l00') construction to the following:
Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Inflection 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:
(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) 1`� 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: 25 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