GW1--06658_Well Construction - GW1_20241112

Vi
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Taylor Ray Boger i41w:AT, R1ON, � I
; . . ;
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I
NC Well Contractor Certification Number A15°OUTER'C:15IN (for,=itiultt=ci"�sedA3i'ells);C}It13IINER(ifap UcalileM&V a:s>,
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 90 ft• 6.25 I i #21 PVC
Company Name M6;1111NER;CiASING:OReCUSFNG,(geo ticrmat<cliiied-iaop)'= ., '' . IekWZ'
OSS-2024-0704 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. I in.
3.Well Use(check well use): ?$Mf8GREEN V E MI-MU` 3IM ;, ; ,k ?
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply ft. ft in.
( � g PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 1ti GROUT.«'5 ,�`iki nff i, •, s zg '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑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 19:Si11YD/GRAY;EL:PKCK'Ci#,ap(ilieaftle) �" s; a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
It, ft. I
❑Experimental Technology ❑Subsidence Control
f20kDIZILEINGftiOG.(attach-addtthi al heels Ciiii s �,,,ai ; " ti
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock hype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 90 ft. 1 OVER BURDEN
90 ft. 225 IL j GRANITE:,r,�?-- ; m
4.Date Well(s)Completed: 9-9-2024 Well ID# ��� ,J
P ft, ft, ti ti ha, �.�
5a.Well Location: ft. ft. N O V 1 2 7074
GONZALO HERNANDEZ ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1t,.:,,,, ••;.:.,t4 L„;
119 OSEETAH LANE HENERSONVILLE, NC 28792 f '`.r' "�.-
ft. ft.
Physical Address.City,and Zip r21';i1tEIUfARKS .ve'' on Ar • a .. 4Z ,'"z
HENDERSON 10009484 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one let/long is sufficient) -7-;...*7 I
N W %LT"' 9-16-2024
Signature oll ntractor Date
I
6.is(are)the well(s): ©Permanent or ❑Temporary 8y signing this forte,1 hereby certify that the uvll(s)was(were)constructed in accordance
with 15A 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 knoll?t well construction information and explain the nature of the
repair ender#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 totprovide 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. '1 SUBMIT _AL INS'I'UCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dif/erent(example-3 rt 200'and 2@100`) 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
1 '
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: Inladdition 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 Centi r,IRaleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
I3a.Yield(gpm) 8 Method of test:
PILLS Also submit one copy of this form ftnthin 30 days of completion of
13b.Disinfection type: Amount: 22 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