GW1--06650_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I 1
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger ,14 w :TliR oNt �� „, ,,,m: . eo-A . . t
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. l 1
NC Well Contractor Certification Number CIS:OUTERVAt;SING.(for«iiidlttreasiediiills};ORI INER(ifappllcaliiiJ ':
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 80 ft. 6.25 ; in' #21 l PVC
Company Name "%16;INNftlI 'C,A"SIN,G.OR,TCIBINC'(eplherioal;cluied4ot ji) x=<e. .,,,, ' '.
OSS-2024-0323 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(Le.Count,State,Variance,Injection,etc.) R. ft. in.
3.Well Use(check well use): 17 SCREENz UWO.'!4W, ' WM at ` .. :P<s w ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. IL le
❑industrial!Commercial ❑Residential Water Supply(shared) l^181GROUT IP Vx ° sONV el ` "1 I` A00,4, 4 m.11'`'r
FROM TO MATERIAL EMPLACEMENT METHOD'&AMOUN T
❑Irrigation 0 ft. 20 it Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 419:SAN11/GRi1`Y, 1`:TACICtf.apiillcableMO ' .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control i
20ZBRILLIN01003(dtael adddiiiiiii heefsi necessary};^ ''Isawo
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It 80 ft. '. OVER BURDEN
80 ft. 405 ft. ( GRANITE
4.Date Well(s)Completed: 9-12-2024 Well ID# _ ft. ft. i; j; _ "r- ,-
5a.Well Location: ft. ft. ' f 'X
GRACE REALTY LLC ft. ft. NUV 1 2 COZ4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
61 FIELD SPARROW LANE HENDERSONVILLE,NC ir'`-••--�'-' ::,---.7.-.-:-,„ ;;,:,;:
Physical Address.City,and Zip ft ft. y _ `t
0al:
HENDERSON 9690820834 THI�En4ARitS� s WELL w s SELFCERTIFIED
� ��
County Parcel identification No.(PIN) I,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w 9-20-2024
Signature of ed ell 7 ntractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifr that the sr'll(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 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:405 (ft.) 24a. For All Wells: Submit this fo{m 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: 60 (ft,) Division of Water Resources;Information Processing Unit,
Ifwrrter level is above casing,me"+" 1617 Mail Service Center,iRaleigh,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 ells:
I3a.Yield(gpm) 2 Method of test
PILLS Also submit one copy of this form vvithin 30 days of completion of
13b.Disinfection type: Amount: 35 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
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