GW1--05600_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Taylor Ray Boger * 4,Sw Tli , t:ES I V M .. ROMMsm ,x ;
`FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 11VOLITER?{'E;SI G.(fur.`trtulttce ise(ttii Ils).OTi`11NER(if.i"p" deahlei Ore ,.4�;=:,
FROM TO DIASIETERi THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it 38 it 6.25 #21 PVC
Company Name : 16c INNL<R;Ct151NG Olt.:F[)31NC'(Leo#6etotaticdosed titijt} $ -r }; r, `+i;
WEL2024-00153 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: H. ' ft. i in.
List all applicable well permits(i.e.county,State.Variance,Ejection,etc.) ft. ft. hi.
3.Well Use(check well use): W> Z
�..6',1;}iSVREE��-;�' �;` dsa;`�3..,'r��r 5`>:,� .,s��.��' '�'�x"ff
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural ❑MunieipallPublic ft. ft. in.
❑Geothemial(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in. ,
PP Y) PP)( g )
❑industrial/Commercial ❑Residential Water Supply(shared) I:xGROD'.� ..H.;, -, ��Fr �`�A ' _ "'am ng'a
FROM TO MA rERIAL EMPLACEMENT METHOD&AMOUNT
['Irrigation 0 ft- 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Meniitoritng ❑Recovery ft. fr. Cap Top with Bentonite Chips
Injection Well: ft. ft.
['Aquifer Recharge ❑Groundwater Remediation +19c,5A1 DYC: V;.ili.Pt1t~I ;riiijilieabri)iVUZteM.Az MIUS~.
['Aquifer Storage and Recovery ❑Salinity BarrierFROM TO MATERIAL' EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater.Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ;
10:IDR1ILLTNDOD attach:addttthnhli aetsifi ,epssai4}W « :.:a
❑Geothetmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Iieating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 38 ft. !I ' OVER BURDEN
8-2-2024 38 ft- 265 ft- ;I GRANITE
4.Date Wells)Completed: —Weil ID# ft. ft.
5a.Well Location: ft. ft. ; s- �,r t..> ¢7,-..:ri
MARY PARKER It. ft.
SEI' Iu2J24
FacilityiOwner Name Facility Mg(if applicable) [t. ft. li
268 HAMBURG MTN RD WEAVERVILLE, NC ft. ft. 1I4:1c: .z Fj^ud'
Physical Address,City,and Zip :Zl g-tNiAV .. ;,r .'" AYPAn`Z M <,., ,,,,s* X-,*
BUNCOMBE 974296184800000 j
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field.one latllong is sufficient) 22.Certification: l'
N w -7'' 8-21-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary �m},.- g b
�si signing this form,1 hereby certify that'the well(.$)was(were)constructed in accordance
By
with ISA NCAC 02C.0100 or 15.1 NCAC 02C.0200 nu Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
Phis is a repair,fill out known well construction information and explain the nature of the
repair under N2!remarks section or ott the back of this form. 23.Site diagram or additional well details:
You may use the back of this page t6 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 cats i'
submit one form. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing 30 (ft.) Division of Water Resou I!ce''s,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Cen''ter',Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: 1n 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
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13a.Yield(gpm) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form'wthin 30 days of completion of
136.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 Reso Ices Revised August 2013
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