GW1--01167_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Kolby Mitchel Sawyers ROVATRII4ONES W.,•,:,...," IS ,, ; W. W-M «;I
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I j
4471-A
ft. ft.
NC Well Contractor Certification Number 15.Ot1TgrittA51AF(fo ttitilti.casiii* )s):UI2 ft tip iC9lit ' a
CLYDE SAWYERS&SON WELL&PUMP INC _ Faont TO DIAMr.TER THICKNESS M.4Tr:RIAI.
+1 ft. 80 ft 825 i 1° #21 PVC
Company Name omono
19100113025 t s 10 a I1 T:I >:t atiOwe ttto,,wooI r-' .,
2.Well Construction Permit#: FROMTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
ft. ft. I. in.
3.Well Use(check well use):
RIUSICgleENNI
Water Supply Well: W V .*
6
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIALAgricultural Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) 12Residential Water Supply(single) ft. ft. in,
industrial/Commercial Residential Water Supply(shared)
A'$;3.Gi2QIJTO:�:.�... :.,WI� ,_ r'.m`"��.z�:, o;): v�s��".� z: ..'-.-,
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 it. Bentonite Pumped
Monitoring DRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge EjGroundwater Remediation
.191.i1 iliklltAVEDMIC<(it a ii iiii1MACU'.r. . idglIMVIAM
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stonnwater Drainage ft. ft.
Experimental Technology Ell Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer ,';201) f5I;1NG 1.L1G;:(ailaelr aridiha aS(shats f'iecessary=)'„ 04.M5 yc-V
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothemml(Fleating/Cooliug Return) 0Other(explain under#21 Remarks)
0 ft, 80 ft• OVER BURDEN
4.Date Well(s)Completed: 1-22-2024 Well ID# 80 ft. 165 ft.
pGRANITE
5a.We ft. ft. ^. T... ...... ,.
CMH HOMES INC ft. ft. .: ,,,f;-+V L
Facility/Owner Name Facility 11311(if applicable) ft. ft.
263 MOSS HILL DRIVE HENDERSONVILLE, NC 28792 ft. ft. �f b LOZQ'
Physical Address,City,and Zip ft. ft. inior Yi'k�ken P11740;?�t '14 UP)j:
HENDERSON 9681109678 120:11EMAIDCSUI, ,. ; _ ' IN; ~ W'i I
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County Parcel Identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N N' 2-7-2024
6.Is(are)the well(s) Permanent or ®Temporary Signa a of el ed onhaclor Date
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By signing th form.1 hereby certifj,that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 0Yes or iNo with 15.4 NCAC 02C.0100 or I5A NCA,C 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the col,of this record has been provided to the rrell owner.
repair under#21 remarks section or on the back of this fin-tn.
23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 165 (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 t@200'and 2(n/00') 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
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Slimily&lnlect Ion Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resource. Revised 2-22-2016
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