GW1--06661_Well Construction - GW1_20241112

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger >.4AvAIT,li Zo: so x }a oa v
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4614-A ft. ft.
NC Well Contractor Certification Number "WUU.TER C:e1S11YC(foicmultt-caicd Yells):OR*I;INER'(il'?apiLcalite}s r3• a i '.
• FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 10o ft. 6.25 #21 Pvc
Company Name 16fINNER.GASNG;UR:'f{IBiNG.(ge'o't6ermutietosed-loaji) WAPZAMPOI
OSS-2024-0219 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. II. in.
List all applicable well permits(i.e.County,Stale.Variance,Injection,etc.) — ' •
ft ft. in.
3.Well Use(check well use): A,I4SCRERII AraltIWPAZ%.,: K W.M M,',mU;Vt,, W- SFr , vrynw4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. ;n.
❑Industrial!Commercial ❑Residential Water Supply(shared)
,1$"Gltni7T� 4' aw l ? .4' x *" <. f2K"` #' ° +. ''t tix`
PROM _ TO MATERIAL EMPLACEMENT METI►OD&AMOL+\T
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. - ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation t9 SAS'DYGRi1;1?EIs"'I',r\CK(if applicable) e a , ':'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
0 Aquifer Test ❑Stormwater Drainage
ft. ft. I'
❑Experimental Technology ❑Subsidence Control
20 0RiLLINOliD .(aftaeli?addilidaril hectsitifaiicuty}° ,<,,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soi/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 100 ft• ; , OVER BURDEN
9-10-2024 100 ft. 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. 1.
5a.Well Location: ft. ft. • a;• -v.1 1
AM CERVANTEZ ft. ft. N(.YV 1 2 2024
Facility!Owner Name • Facility ID#(if applicable)
874 S MILLS GAP ROAD HENDERSONVILLE, NC 28792 ft
ft. ft. I t:':o',.p 3
Physical Address,City,and Zip x21!R1~lti'IARKS ,.;st s- '?( �' '' ,- '` w, `t1'F`l
HENDERSON 100007171 THIS WELL WAS SELF CERTIFIED
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I
(if well field,one Iat/long is sufficient)
N lY
�.,r 9-17-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)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: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knower well construction information and explain the nature of the
repair under#2I 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: 1 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3@200'and 2ca 100') construction to the following: 1
25 Division of Water Resoures Information Processing Unit,
(ft.) c ;
10.Static water level below top of casing:
If water level is above casing,ttse"+•• 1617 Mail Service Center,:Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 __ (in.) 24b.For injection Wells ONLY: in laddition 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
(gpm) 15 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy a this form within 30 days of completion of
13b.Disinfection type: PILLS 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