GW1--06695_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , ,
Taylor Ray Boger 14,w EIMO SUMV � � M" 4
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15:�OUTEWCASING'(fo`r indltt-cased t'ells)';t3R1LNEIt(if. ppTerilile) ^' .4`.::.;
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 37 ft• 6.25 , in. #21 PVC
Company Name 46 1NIVCR:RA51'NG;Offs'l t113114G`(t eot6erm it cl`o'sed=loojt)-� '' ', 4
W E L2024-00474 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): 7;?St3R):ENOPM " 'M I.- ; ' , . g; &. .... Y ' :'',
Water Supply Well: FROM • TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) f8'GROUT 7i " �� "° �" 'fit 0 `R
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well: " _
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ' ❑Groundwater Remediation i119:ySAND/GRiI!';El>:P,r'<(3K:{if itiPliettbli —'' ,s' ;Vm M
❑Aquifer Storage and.Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
0 Aquifer Test ❑Stormwater Drainage •
ft. ft. j
❑Experimental Technology ❑Subsidence Control
naDRILLINOLDIZOttieliiidditiriatitieifsAtitieastiff)XWMATWM,MWA
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 c ft• 37 ft• OVER BURDEN
37 ft• 525 ft• .--- -GGRANITE -
10-14-2024 1: , : ,, ,
4.Date Well(s)Completed: Welt ID# ft. ft. r c -C:,,•'A.:; +P 1....,
5a.Well Location: ft. ft. AI
DEPT OF TRANSPORTATION/B.ORR N"V 0 8 2024
ft. ft.
Facility/Owner Name Facility ID#(if applicable) R ft lf, ,f`::' r"' .74..:: t1M
1 RESORT DRIVE ASHEVILLE, NC 28806 r''```- ';t.,
ft. ft. ti
Physical Address,City,and Zip „2teftE114ARICS' ` '' o;: , ,' - `'."
BUNCOMBE 963950833-400000 THIS 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 lat/long is sufficient) Iv i
N Wgr. 10-22-2024
Signature of ed ell C ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
8y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or/5A NCAC 02C.0200 Well Coastnetion 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.
If this is a repair,fill out knowzt 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
A.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. c c SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 525 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2(100q construction to the following: 1
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.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 ofl 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) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS 35 Also submit one copy of this fotim within 30 days of completion of
13b.Disinfection type: Amount: 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