GW1--04721_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14 WAFER ZONES
FROM TO DE:SCRIP HON
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ►f• 78 ft. 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSS-2024-0035 FRonr ft. 'ro ft. DIAMETER in. Tlucxvess MATERIAL
List all applicable well permits(i.e.County,State.Variance,injection,etc.)
-
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM 10 DIAMETER- SLOT SIZE THIC KIN ESS M VIM AI. _.
DAgricultural ❑Municipal/Public tt, ft. in.
❑Geothermal(Heating/Cooling Supply) YResidential Water Supply(single) R ft• in.
( tv� g PP Y) PP Y
❑lndustrialiCommercial ❑Residetttial Water Supply(shared) t8.GROt f
ERULI rU N1 V1Eltl,t1- -F.NINA(EMI'\I MT 1110D S..1V1(11 AI_
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: - -
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chip_
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable"
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO NI 1'reuLl% EMPLAreME:vr MernoD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage - - -
rt. rt.
❑Experimental Technology ❑Subsidence Control
21).DRILLING LOG(attach additional sheets if nec . )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.toil/rock type.grain sire,etc.)
"'Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 78 ft. OVER BURDEN
7-15-207.4 78 ft. 205 ft- GRANITE
4.Date Well(s)Completed: --Well ID#
ft. ft. i * y'�^,
5a.Well Location: �:``` ' i�1 L>j
ft. ft.
CMH HOMES ft. ft. AUG 1 2 CO?4
Facility/Owner Name Facility ID#(if applicable)
98 WHISPER MOUNTAIN ROAD HENDERSONVILLE,NC 28792 ft.
rr. ' ,'; ' • ' -"„' , I�i t
Physical Address.City,and Zip 21.REMARKS
HENDERSON 0611752066 THIS WELL WAS SELF-CERTIFIED 1
County Parcel Identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) - am.
N w 1 07-17-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 hereby certify that the uull(s)was(were)constructed in accordance
with 154 NCAC 02C.0/00 or/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 421 remarks section or on the back of this forth. 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.vcu can
submit one form. 1T SUBMI AL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(a l00) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
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 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
RIG 24c.For Water Supply&injection Wells:
13a.Yield(gpm) 20 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 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