GW1--03549_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD T r Internal Use ONl l
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A. ft. tt. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 140 It. 6.25 in. #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-lout
WEL-2023-00509 I'ROMI ir) DIAMETER MATERIAI.
2.Well Construction Permit#: ft. fL 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 SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
ft. It. in.
❑Geothermal (Heating/Cooling Supply) aResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACLMENI MEl'HOD&AMOUNT
❑Irrigation 0 f• 20 tt• 'Bentonite Pumped
Non-Water Supply Well: -
❑Monitoling ❑Recovery IL It. Cap Top with Bentonite Chips
injection Well: ft. tt.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.P:M(h(if applicable)
MROMI ' '10 M110:R1A1. EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stop nwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control --
-
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑'bracer FROM '10 DISCRIPI ION Ica nr.hardness.soiUrock type,krain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 140 ft. OVER BURDEN
4-1-2024 140 ft. 225 rt• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. _ fc,
....- ,
5a.Well Location: ft. ft. F.
• `.r 'JE L s
CHASE AUSTIN ft. ft. JUN 1 2 1014
Facility/Owner Name Facility 1134(if applicable)
ft rt. Irk' f 1 Fs•�^
MURPHY HILL ROAD WEAVERVILLE, NC +►a .at1,dl
ft. ft. r.,-- 1s.k.;
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 9744628045 THIS WELL VVAS SELF-CERTIFIED
County Parcel Identification No.(PIN) 1
I
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lal/long is sufficient)
N µ, 5-12-2024
Signature of led Well ntra or?‘''''. Date
6.is(are)the well(s): 2IPermanent or OTemporary By signing this form,1 hereby certify that the wilts)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
((this is a repair,fill out lauwn 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 wills ONLY with the same construdion,von can
submit one form. n G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths different(example-3@200'and 20110(Y) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:`to (ft.)
It-water level is above casing,use"f." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection 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) 1 0 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013