GW1--06649_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1
Taylor Ray Boger I4;,FYA<FEICZOi+t)5 `.BAR` I,z x II . �-.� y . ,x>
Y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
• 4614-A it. ft.
NCWell Contractor Certification Number
L20LITER`e SING`(foe"inultt-cased:''ellsMRILINElt(ifc ti lieibler Z
_ FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL& PUMP INC +1 ft. 120 ft- 6.25 : in. #21 PVC
Company Name ;t'ti:1NNERWASIl\,G.URnF1IBINGO(geo`thermidcto'sed-IoOp ="`; . A a 'Ax
OSS-2024-0578 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 47 SCREEN ",,.:z ,M ._- 4 ` ? K ., t
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. -
ft in.
❑Geothermal(Heating/CoolingSupply) OResidential Water Supply h' tt. in.
PPY) PPY
❑IndustrialiComnuercial ❑Resideniial Water Supply(shared) S'fGRnUT RA
`" AWAf� � '' `r` '`$ `.`m 7
FROM TO _ MATERIAL EMPLACEMENT mutton&AMODNT
❑lrrigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Ivtonitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation i4 Si'ND'1GRAF,EL,PACh(if iiptilica Ile "' 4
FROM TO MATERIAL EMPLACEMENT IIETIIOD
❑Aquifer Storage anciRecovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft, ft. I
❑Experimental Technology ❑Subsidence Control
0101,DTLiELINOIL (giber idddiiinalslieetkif nffcessary) gwwaR r"i'nn-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soiUrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 120 ft• OVER BURDEN
9-13-2024 120 ft• 465 ft. w-_ -.GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft, v t,,-,.C.'.I,— it fi.,d
5a.Well Location: ft. ft.
CMH HOMES INC ft ft. NOV 1 2 2024
Facility/Owner Name Facility ID#(if applicable) ft, ft. Ire`:.: s:E -,-: ? ,-r.y; .-,r- . t 1. x.
67 DANIEL RIDGE DRIVE HENDERSONVILLE, NC ft. ft. �;�r;4=,d..;
Physical Address.City,and Zip $0 J2EMARK:S t `„. -. - - 7,0
HENDERSON 1009246 THIS 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 Iatilong is sufficient)
N W - e r`k L • ( 9-15-2024
Signature of I.: ed ell tractor Date
6.is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or i5A NCAC 02C..0200 Well Construction Standards and that a
7.is this a repair to an existing well: [Wes or Iallo copy of this record has been provided to the well owner.
if this is a repair,fill out knoisst well construction information and explain the nature of the
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 same construction.you can
submit one form. 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@100`) construction to the following:
10.Static water level below top of casing: 50 (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 iaddition 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
(gpm) RIG 24c.For Water Supply&Injection!Wells:
13a.Yield m) Method of test
PILLS Also submit one copy of this form within 30 days of completion of
136.Disinfection type: 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