GW1--03550_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal l ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM It) of:su It IPIION
Well Contractor Name
ft. it.
4614-A ft. ft.
NC Well Contractor Certification Number Is.OUTER CASING(for multi-cased welts)OR LINER(if applicable)
FROM 10 DIAMELER 1HICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 72 rt. 6.25 in. #2i PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WEL-2023-00492 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable Hell 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 ❑Municipat/Public
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
RROM TO MATERIAL EM PI.ACEMENT METHOD&AMOUNT
❑irrigation 0 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. rt.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MAFERIAI. EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier R, ft.
[Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessan•)
OGeothermal(Closed Loop) ❑Tracer FROM I O DESCRIPTION(color,hardness,soit/ruck type,grain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 72 it. OVER BURDEN
3-19-2024 72 ft- 205 ft- GRANITE
4.Date Well(s)Completed: _Well ID#
ft. it. w. .1
Sa.Well Location: ft. ft. t. t i
�`r. �`.e 4.. , V f
t..
LOREN LUSK - ft. _.- IL - JUN 1 2 2014
Facility/Owner Name Facility ION(if applicable) -
ft. It.
30 GARLAND BALL DRIVE, ALEXANDER, NC 4411421'si�erz 9"A.:44,1
R. ft. D'f r.4 jt 4
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 97212924400000
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 µ 3-22-2024
Signature of led Well ntractor Date
6.is(are)the well(s): ®Permanent or ❑Temporary By signing this form.I hereby cernfy that the wiles)was(were)constructed ted in accordance
with ISA NC.4C 02C.0/00 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Mu copy of this record has been provided to the well owner.
((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 it'necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMI1TAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 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 2@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".1-- 1617 Mail Service Center.Raleigh,NC 27699-1617
ILBorehole 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) 15 Method of test: _
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:_ Amount: 2O 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