GW1--06711_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Internal Use ONLY: u
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 14,0,-ATER*`LONEs ,.r , '.,,!,. . �;. ,,Liz
• FROM _ TO DESCRIPTION
Well Contractor Name ft. ft. I '
4614-A ft. - fL
NC Well Contractor Certification Number a x5.OUTER CASING ftiMmulti-Miftd Vel )OR LINER(if au.ttcable) ,' „ , „;, 'i.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 fL 56 ft- 6.25 #21 Pvc
Company Name (] 16.INNER CASING ORTISSING'(ge,6tlierm"atclosed loop) �`, ,. ,
2.Well Construction Permit#:WEL-2024-00429 FROM ft TO ft. DIAMETER'in THICKNESS MATERIAL
List all applicable well 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
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
18.GROUT, ''.: ,ems
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft. Bentonite Pumped
Non-Water Supply Well: fL ft. Cap Top with Bentonite Chips
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '19.-SAND/GRAVWPACK(ifapplicable)_. 5: ` a,'f' 0,r,- 0,,,;''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.'DRILL1NG LOG-(attach addttiatial sltects if necessary)",z xi f 4,. .'ism:
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitlrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft' 56 ft• OVER BURDEN
10-08-2024 56 ft• 265 ft* .GRANITE n _
4.Date Well(s)Completed: Well ID# ft. ft. 't ,�. 4., i 1 , .,
5a.Well Location: a p u" �`
CHAD CARTER fL fL ft. ft. NOV ® 8 2024
Facility/Owner Name • Facility ID#(if applicable) -
92 FERRY RD ft. ft. Ifi P_.r,r.a
ft. ft. L:v i.i:`,r ia:3
Physical Address,City,and Zip 21/R.ENFtARKS ,,,Aie," `` '?..E :' r. �,L. , ,;;,',
ASHEVILLE • 9636011701 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: I
22.Certification:
(if well field,one latllong is sufficient)
N N 10-09-2024
�v
Signature of red W ell ntractor I Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cert(f that the well(s)was(were)constructed in accordance
with 15A KCAL'02C.0100 or 15A 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 know:well construction information and explain the nature of the
repair under#11 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-water supply wells ONLY with the same construction,you can ,
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (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 a@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"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
30 RIG 24c.For Water Supply&Injection WI lls:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county healthy department of the county where
13b.Disinfection type: Amount:20
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013