GW1--03527_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM 'FO DESCit!PIIO'
Well Contractor Name ft. ft. - -
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 R• 79 ft- 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal clnsetl-lanjs)
2.Well Construction Permit#: OSS-2023-1209 FROM ft TO ft. DIAMETER in. 'MR .xEss MA ER1At.
List all applicable well permits(i.e.County,State.Variance,injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: 1,ROM To DIAMETER NMI s17.F_ 1111(I�NF.,,._ I NI n ERA M.
It. ft. in. ---- -----
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) n. fr. in.
( g PP Y) PP Y
❑industrial+Commercial ❑Residential Water Supply(shared) 18.GROUT
FRUGM I AL1 I ER1AT EMPLACEMENT MF:tIIOD&AMODAF
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Mon itoring ❑Recovery ft. n• Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery OSalinity Barrier FR°A1 To ALcreRl,u. EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
DGeothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft. 79 ft. OVER BURDEN
5-22-2024 ft f`'
4.Date Well(s)Completed: Well ID# 79 165 RA IT EI f -.._t
rt. ft. r V �.•:
Sa.Well Location:
CMH HOMES INC ft. ft. JUN 1 2 2024
Facility/Owner Name Facility IDk(if applicable) ft. ft. In ;l:�wf 1 P'�' e:$fix,
ST PAULS SUBDIVISION#8 HENDERSONVILLE,NC rt. - ft. DJrw?C4
Physical Address.City,and Zip 21.REMARKS _.
HENDERSON 0602612965 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 5-23 2024
Signature of ed e11�Cntractor Date
6.Is(are)the wells): Permanent or ❑Tern ra
well(s): rY By signing this form,1 hereby certify that the 1tullft)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remarks section or on she 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: 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. cG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For Al Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi Jerent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 30 (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.) 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 Center,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 0 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-t North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013