GW1--06660_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: I
II
This form can be used for single or multiple wells '
1.Well Contractor Information: II
Taylor Ray Boger 4tWATERZZONE8 ":, :1-X M WIW
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. . ft. 1 1
NC Well Contractor Certification Number tIS OUTERtASING itenidttr-case ti`clls);UREINEFOI iip lieablee)- ; U' >'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 47 ft. 6.25 in• #21 PVC
Company Name
lti:MER ASi1 G:DIOTUBING in tterttinalnieif-186ji)1 k
OSS-2023-0486 FROM TO DIAMETER THICKNESS . MATERIAL
2.Well Construction Permit#: ft. ft. : in.
List all applicable well permits(i.e.Couny,State,Variance,Injection,etc.)
ft. ft, in.
3.Well Use(check well use): M.SQBEEN, %�`_.,: AV' : ' S.:W ", `:.. : . :w
Water Supply Well: • FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft ft. in.
❑Geothermal Heatin Cooling Supply) OResidential Water Supply ft. fL in.
( g/ PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) iff.GROUT �..4,0, :". s e, ti4, , :
FROM TO MATERIAL EMPLACEMENT METHOD&AmouNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. r Cap Top with Bentonite Chips.
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation l9;PS'ANtifGRANEDUctOit nifilleitire).WaVagarMgatalk
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft, f
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control :013()'G .
20:4DRIC131� (attach:additiopa) 6eitiaoeeeiii—M .r M�,;�`r" ZWR*
❑Geothermal(Closed Loop) ❑Tracer • FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft. 47 ft. OVER BURDEN
47 ft. 145 ft. GRANITE
9-12-2024 T ��
4.Date Well(s)Completed: Well ID# R. ft. .i wr A:._,'n.-a a N-s;,Li'
5a.Well Location: R. ft. NOV 1 2 2024
2020 BUILDERS LLC ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft ft. "•i1-,'`;;; , ; ? --,, J Us:
882 WASH FREEMAN ROAD HENDERSONVILLE, NC ft. R. r:.;,.: "Tt-`,)
Physical Address,City,and Zip 2If,RE4fARK5(Z s`..0 :0011MAVO., WSW, W u'?s
HENDERSON, 0603521126 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 Iat/long is sufficient) I
N W -'. 9-19-2024
Signature of ed ell ntractor Date
6.Is(arc)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the miffs)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knonnt well construction information and explain the nature of the
repair under It21 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,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft,) 24a. For All Wells: Submit this f Arm within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
I
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
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611.Borehole diameter: (in.)2524b.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.) l
Division of Water Resources,Underground Injection Control.Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent;r,IRaleigh,NC 27699-1636
(gpm) 30 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013