GW1--06698_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Taylor Ray Boger VAWAVEItZONE5 , i t,,.. ;, .
FROM TO DESCRIPTION
Well Contractor Name ft. ft. !
4614-A ft. ft. • !
NC Well Contractor Certification Number :15.'O'UTER+Cx1SI1YG.(for-maltrcased<it'eUs)`UR`t IhER(if nplicLitCj zira
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt• 61 It 6.25 'in. #21 PVC
Company Name 1l6 INNEItiC',ASSING'OR;TVBINO�(e tttiiiiir l:clo"sed400p)?: .' z,x,
WEL2024-00535 FROM TO DIAMETER THICKNESS MATERIAL2.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): 1 17 SCREENIF K w � €-Ii >'' , V f R .... wh; z?
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
•
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply ft fL in.
( Ej g PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) 3S"GR U'Lt. ''. � `' - � ' ``; ��`
FROM TO MATERIAL EMPLA(EMEN METHOD&AMOUNr
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite ChipE
❑Monitoring ❑Recovery •
Injection'Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation k19:SAKI)/GRAYEI,PACIC{ifapnitealtle) ;S. . �.�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
12eDR[LLINGlLO Xattiel additfi tinFsheeis'iEifeceeiaty) KCZWa.,•w...
❑Geothermal(Closed Loop) ❑Tracer FROM TO _ DESCRIPTION(color,hardness soihlrock hype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 61 ft. OVER BURDEN
10-18-2024 61 ft• 125 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. . -: - -- �•- -
Tzn
Sa.Well Location: ft. ft. d .' `:.k,.a.- •`, i,r. is..?
ANTHONY GENTRY ft. ft. NOV 0 8 CO24
Facility/Owner Name Facility lOb(if applicable) ft. ft.
808 MACEDONIA ROAD ALEXANDER, NC 28701 ft. ft. i''`.""-''`'-1 ;" -'' ``t '
D e u °i•3
Physical Address.City,and Zip = a1 REi 4A121t8f4aZ?r✓ ` 'ZW" 'mr, ,ziox
BUNCOMBE 9721029284 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it•well field,one lat/long is sufficient) i.
N W C (I 10-22-2024
Sienature of ed ell ntra n. Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 hereby certiA that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well 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.
If this is a repair,fill out known well construction information and explain the nature of the
repair under t121 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: 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(ic200'and 2®..100`) construction to the following: 1
,
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 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
(gP RIG 24c.For Water Supply&Injection Wells:
) 30m 13a.Yield Method of test:
PILLS Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type: Amount: 15 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 Resources Revised August 2013