GW1--03528_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger 44 WATER ZONES
FROM '10 DESCRIPTION.
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINO((if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 n• 95 ft• 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
OSS-2023-1204 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable srell permits(i.e.County,State,Variance,Injection,etc) ft ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 10 DIAAMETER THICKNESS SIZE THHKNESS M VI FRII I.
['Agricultural ❑Municipal/Public ft. ft. in.
ft. ft. in.
❑Geothermal Heatin Coolin Supply) OResidential Water Supply(single)❑industrialiCommercial ❑Residential Water Supply(shared) 18,GROt1T
FRUM TO MATERIAL F:MPLMF MENT METHOD Si AMOU '1
❑irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
['Aquifer Recharge ❑Groundwater Remediation 19.SAND'GRAVOCKCK(if applicable)
__FROM 10 \L\'!FRIA!, EMPI.ACFM FNI'METIIOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
['Aquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I—TO DESCRIPTION(color.hardness.tad/rock type.grain sire.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 115 ft. OVER BURDEN
5-21 v2024 95 ft• 405 n• G TL � /
4.Date Well(s)Completed: Well ID# n ft. le...— .� V a [\
` LPL.:, L%
Sa.Well Location: ft
• n• JUN 1 2 2024
CMH HOMES ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ham:r,g4 i l r 'r.f.4tg L Uf I
82 MARK FREEMAN ROAD HENDERSONVILLE, NC 28792 ft ft. DWG,lC'3
Physical Address,City,and Zip 21 REMARKS
HENDERSON 06026271 755 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well field,one latflong is sufficient)
N W 5-23-2024
Signature of ed ell ntractor Date
6.is(are)the well(s): I(Permanent or ❑'Temporary
By signing this form,!hereby certify that the upll(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or/3A NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: ❑Yes or E No copy of this record has been provided to the well owner.
If this is a repair.fill out knelt,:well construction information and explain the nature of the
repair under 1121 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.rou can
submit one form. SUBMITTAL INSTUCTIONS
9.'I'otal well depth below land surface:405 (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 2Qr 100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"4" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Injection Wells ONLY: In addition to sending the fonn 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
I3h.Disinfection type: Amount: 30 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