GW1--06652_Well Construction - GW1_20241112

i '
1
I. •
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger ovegrt t xoy .sm of " .:,~ ',,,N4t0.`4!':,1V4AU:A.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 1S;1OII CER';C1SINGE(foc iiiulti casedii'ells)`OR Lh1ER7(if apPlicelilej'* ,
FROM TO DIAMETER' 11IICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 46 ft• 6.25 I in. #21 PVC
Company Name • 15361INIMR1Ci1.11?GUR,Ti1BING°(atit1iiiinnl,cto'sed-tuifx) ; ` zUMMWMA
OSS2024-0311 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): z w ,,, W
�;17.;SGRECN�% <:�...,���.,�x.�% r`>�,_.�x�`�>�,. � u�` « k ...A=,,M
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R in.
tt• ft. in.
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) I1gRro°U c' ;'1-"- .AT xz E `` �� ''" "
FROM TO MATERIAL E\iPLAC:ED7EhT'111ET110DSAMOIINT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well: -
ft. ft. ' Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19f SAND`I.OltAV,ELTA"t?K^(if,aiijilieable)Mei,W s W MTAWW`k i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage - '
ft. ft.
❑Experimental Technology ❑Subsidence Control ' ,,_
':20 D.RILL;NG4Fi]£'r,(dtiacl£additii4ilitseetiiTiiiiewsatr.) � -c L` :'
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 46 ft. ! OVER BURDEN
9-19-2024 46 ft. 705 ft• f=GRANIT ,-
4.Date Well(s)Completed: Well ID# ; 1---,
ft. ft. - na,. :-'R. ,: eit Il. ....
5a.Well Location: ft. ft. S
NOV 1 n 20LAr F
KAREN PENIX ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ►f;::.:;T.£.'.. ;iI' -'.- . -.'j..-i`
SUGARLOAF MTN ROAD LOT 8 HENDERSONVILLE, NC ,...
ft. ft.
Physical Address.City,and Zip .421:RE'C/iims .;"�Qw a as `z `"." N � `•`�
HENDERSONVILLE � �� � �������� ��*� ts`�� �
THIS WELL WAS SELF CERTIFIED
County Parcel Identification No,(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: !
(if well field,one Iat/long is sufficient) 22.Certification:
N w 10-23-2024
Signature of ed ell ntmctor • Date
6.Is(are)the wells): ®Permanent or ❑'temporary By signing this form,I hereby certify that the well(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 DNo copy of this record has been provided to the�well owner.
If this is a repair,fill out knoira well construction information and explain the nature of the
repair under#2/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
S.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: 705 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r,200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centerr r!R, aleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In lad'dition to sending the fonn 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.) I '
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: I I g
1 RIG 24c.For Water Supply&Injection Well's:
13a.Yield(gpm) Method of test
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30 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
I .