GW1--03524_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can i e used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers 14.WATER ZONES —
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A rt. ft.
NC;Well Contractor Certification Number I5.()LITER CASING(for mu1* edlwells)9K LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 56 It. 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
OSS-2024-0207 FROM 10 I)IAMEI'ER I HICK NESS MA IN RIM.
2.Well Construction Permit#: ft. ft. in.
List all applicable sell permits(i.e.County.Sate,Variance,Injection,etc.) ft ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRo\I To DI ta15 0 k 51,01 SIZE: I IICKNLSS NI s II RI tt. _
Agricultural ❑Municipal/Public D. it. In
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply 11' fL in.
g g PpY) pPY
❑Industrial/Commercial ❑Residential Water Supply(shared) _tt1.GROUT
I+kU\I TO \l ATERIAL EWE N(EMI.ST METHOD&\MOUNT
❑irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: -
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: It. ft.
IlAquifer Recharge ❑Groundwater Remediation l9.SAND/GRA\EL PACK(0 applicable) . ,'
1.ROM TO MATERIAL I N.MPLACEMENI MIEI 1101)
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. it.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additiotiliabeets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM 10 DESCRIPTION(color.hardness,soil/rock tope.grain size,efc.l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 56 ft. OVER BURDEN
5-30-2024 56 ft 605 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft ft `r —r
5a.Well Location: ,1` 'i . t_ft. ft.
CMH HOMES INC _ ft. ft. JUN 1 2 2024
Facility/Owner Name Facility IDS(if applicable) ft. ft.
Unit •
3664 SUMMER ROAD HENDERSONVILLE, NC 28792 Irf�if '"F'�Pr�" `�`�
ft. ft. I DiNC$3+t a
T'hysical Address.I ',.and Zip
21.REMARKS
HENDERSON 0620028826 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 ladlong is sufficient)
N W 5-31-2024
Signature oqgro*s
Well Contract Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair.Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hack of this firm. 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: 605 (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(aj200'and 24100') construction to the following:
10.Static water level below top of casing 180 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24h.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 Wells:
13a.Yield(gpm) 1 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 OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013