GW1--07539_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
14.WATER`ZONES- °= " ` . ' , ' ;
TAYLOR RAY BOGER FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft. I 1
NC Well Contractor Certification Number I5.OUTER`CASING(for`multi-cased wels)OR LINER(if t is icrihle) 7:
FROM TO DIAMETER). THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft• 72 it 6 1/4 ;in. #21 PVC
Company Name - t6.INNER CASING OR TUBING(geothermal closed-loop)"•°,', , •<.
OSS-2023-1182 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublie ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply fr. ft. in.
� gl g PPY) PPY
❑Industrial/Conunercial ❑Residential Water Supply(shared) IBd:GROUT y,' a �: `�_;
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 ;l9.SAND/GRAVEL PACK(ifapplicahle) a.
FROM TO MATERIAL'. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. !
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '20.DRILLING LOGS(attach additional beets if necessary)_: '-."` :
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 72 ft• OVER BURDEN
09/15/2023 Well ID# 72 ft• 465 ft• GRANITE
4.Date Well(s)Completed: ft. ft. '.
.
-: -s. ��
5a.Well Location: ft. ft. 'b=-n, t./ 1_„i .1
CMH Homes ft. ft. NOV 2 i 2023
Facility/Owner Name Facility ID#(if applicable)
ft. ft
68 Indian Cave Park Rd, Hendersonville, 28739 fai , .
t-/i':
ft. ft. I. C, .,( ;,}
Physical Address,City,and Zip 21 REMARKS a. r ,,
Henderson 9558036170 '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N W 11♦'•
09/22/2023
Signature o riffled Well 4�or i( Date
6.Is(are)the well(s): ElPermanent or ❑Temporary By signing this form,I hereby certify that i e well(s)was(were)constructed in accordance
with 1.5.1 NCAC 02C.0100 or 15A IVCAC 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 I
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
8.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 sante construction,you can
submit one farm. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface:465 (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@200'and 2 a 100) construction to the following: i'
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:20 (ft.)
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:
(i.e.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
(sP ) Also submit one copy of this form(within 30 days of completion of
13b.Disinfection type: PILLS 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