GW1--06655_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1
Taylor Ray Boger 0141VATERIONEMS14,. 7. ' A AK WW`0 r. ..::
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ' ft.
NC Well Contractor Certification Number ' 1VOt TER CilSING(focrmalfi-cas dxsrells):OBaisINER(if eppllsahte) N; . '',
FROM TO DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 112 ft. 6.25 in• #21 i PVC
Company Name 1`6'INNER°Ci1SINGMTUBING.(gepflierioirteeloied=loajiMa: W--K .a.
OSS-2024-0289 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit Al: ft. ft. I in:
List all applicable well permits(i.e.County,Stale.Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): lVSCREEN V .2R9KaPWVAKI1
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. in.
It. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(sin le)
❑Industrialt'Commercial ❑Resideniial Water Supply(shared) t1VGADUx'� `"c`;„`'' , 1 VONtt` € � ' W . '`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. rt. Cap Top with.Bentonite Chips
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑GroundwaterRemediation 19i85011/GR'rl'Y.ECItt1:C3K'(i[apitlteable1, M .,, ' MMIWZr „+
❑Ayuifer Storage and Recovery ❑Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
ft. ft. i
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
031Ati L1 Gil;CIialit#'oeK ailrlitiii"nsiT,cheats°iC.'uecevsaef) iMET'W 1
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soilrock type.groin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt• 112 ft. ! OVER BURDEN
9-26-2024 112 ft. 365 ft. GRANITE
4.Date Wells)Completed: Well ID#
5a.Well Location: ft. ft. ° '.� ...1..- e, tf 1.,.,tl.,.Fi
CMH HOMES ft. ft. 1 NOV 1 2 2024
Facility/Owner Name Facility lD#(if applicable) ft ft. 1
241 MCCRAWS HILL DRIVE HENDERSONVILLE,NC 28792 lr,` . """" ' L!
ft. rt.
Physical Address,City,and Zip ;*21'Rl tl1ARKS ,.', ,, 4;1 �, - � ;M4.,,. `*4
HENDERSON 9589745776 THIS WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one Iatllong is sufficient) 22.Certification:
—ra
N W L
10-22-2024
MAit
Signature of ed ell tractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 0.2C,.0200 Well Construction Standards and than a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to the well owner.
If this is a repair,Jill out knout:well construction information and explain the nature of the '
repair under#21 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: 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: 365 (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths If different(example-3 a,200'and 2®100`) construction to the following: I'
1'
10.Static water level below top of casing 60 (ft.) Division of Water Resources,Information Processing Unit,
limiter 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 Cent'r�Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
I3a.Yield(gpm) 3 Method of test:
PILLS Also submit one copy of this form within 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