GW1--04730_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certilicatiun Number a�- r- multi-cased wells)OR 11 YER(if up able) _
FROMa TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 85 ft. 6.25 in• #21 PVC
Company Name c `i a ''y,) 1IR TURING(geothermal closed-loop)
OSS-2024-0032 FROM TO DIAMETERTHICKNESS MATERIAL
2.Well Construction Permit#: ft. D. in.
List all applicable well permits 0.e.County,State, Variance.injection,etc.) n• ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DI-%MCI ER_ SI r)t WETlilt ESESS MATERIAL
• ft. ft. in.
❑Agricultural ❑MunicipalfPublic
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. R. in.
❑IndustrialiCommercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
❑Irrigation 0 n. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. t. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Hum TO MATERIAL F'NtPI.ACE MEN I'METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage - rt. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.n/illrock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 82 n• OVER BURDEN
7-15-2024 82 ft- 285 i•'• TE
4.Date Well(s)Completed: -Well iD# n, ft. � `�.,• `►,_ ' %V I.-.
L.,
5a.Well Location: ft. n. AUG 1 2 2024
CMH HOMES INC ft. ft.
Facility/Owner Name Facility iD#(if applicable) n. ft. 11-4::r:71-4. ", r---AA,-,- ,r`+
110 WHISPER MOUNTAIN ROAD HENDERSONVILLE,NC ft. ft. ire, -.'
Physical Address,City,and Zip 21.REMARKS
HENDERSON 0611 7556221 THIS WELL WAS SELF-CERTIFIED
County Parcel identification No.(PIN 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one tat/long is sufficient)
N W 7-18-2024
Signature of ed ell ntractoi Date
6.Is(are)the well(s): l Permanent or ❑Tern ra .
( ) rY By signing this form,1 hereby certify that the bulks)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under b21 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: 285 (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(0200'and 24100) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:40 ({t)
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:
(ie.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:
I3a.Yield(gpm) 7 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 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