GW1--06664_Well Construction - GW1_20241108

i
I ,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger FROM ro DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15 OUTEWCASING4frii iuultikasetl',tf'elJSOR`t INER itfiippli able)"". ' .,',,'. .
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL& PUMP INC +1 ft. 52 ft. 6.25 #21 PVC
r,.
Company Name �Ifici[NNER;Csi1ST1VGf)R�'CTSBTNG;(fiaottiermal closed-toop),t 't ?,z. , .,..w. -,t>
DGS-085W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) —
ft. ft. in.
3.Well Use(check well use): ar �, t n
;17xSCREENh� a� � b an R • ,a:I
Water Supply Well: FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. m ,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply ft. ft. in.
( g/ PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) #189GROUT, N3,, '
FROM TO MATERIAL EMPLACEMENT n1E'11101)&AmouN r
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: ,
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chipt
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 419.iSANDIGRrt`V;EL PACK'(i(FP'licable l..,,. U,SNM.w,."si ?,V x :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer'Pest ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 72f ©R1liLTNGTtit?G(aetieh`addttiouithsheefsaf,uececsarh " ,,I ;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 52 ft. OVER BURDEN
10-25-2024 52 ft- 225 ft. GRANITE-,T
4.Date Well(s)Completed: Well ID# ft. ft. I ..Rom..f.,,,'fl._ '''ll ;' I.
5a•Well Location: ft ft Al
LINDSAY&TIFFANY GREY It. rt. NOV ® Q Z02 9
Facility/Owner Name Facility 1Db(if applicable) ft, ft. lr O: ,C:- :'_"-.7..',;:'-',!--,; ,''
15 PENNY LANE WAYNESVILLE, NC 28785
ft. ft.
Physical Address.City,and Zip )21„ EMARK5 . 11%S'.:z. AMI , '", "`,,,W' ` . .. ,` =xa
HAYWOOD 8608-77-2335 WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
N W "1"" I: 11-4-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Teniporaty By signing this form,I hereby certh that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0/00 or 1.5,4 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 1121 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-stater supply wells ONLY with the stone construction,you can
submit one form. SUBMI .IAL INSTUC'I'IONS
9.Total well depth below land surface: 225 (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@l00') 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"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter 6.25 (in.) 24b.For Injection 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: 1
(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
(gP ) 40 RIG 24c.For Water Supply&Injection Wells:
13a.Yield m Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 22 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
I