GW1--03521_Well Construction - GW1_20240612

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 'f0 DF:S('irieriON
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number I S.Ojj'TER CASING(for multi-cased wells)OR LINER Of applicable)
FROM 7'O DIAMETER 1111CICNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 75 ft. 6.25 in• #21 } PVC
Company Name 16.INNER CASING OR Tt!BING(geothermal closed-loop)
OSS-2023-0737 FROM DI.SMI TER 'THICKNESS MATERIAL
2.Well Construction Permit#: _ ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) I R ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO Ito MEI ER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑MunicipaVPublic R. ft. in.
ft. ft.
['Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑tndustriallCommercial ['Residential Water Supply(shared) i8.GROUT
FROM, I r0 I \L\'FERIAL FM PI.AC EMIF:NT METHOD&:\MOUNT
❑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/GRAVEL PACK(if applicably_
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT 1fETt10D
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
-
ft. ft.
❑Experimental Technology ['Subsidence Control
20.DRILLING LOG(attar
ft. (attach additional sheets if necessary)
❑Geothermal(Closed Loop) TO DTracer FROM DESCRIPTION(color,hardness.soiVrock Rpe.grain sire,etc/['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 05 OVER BURDEN
4.Date Well(s)Completed: 5-7-2024 Well ID# 75 fa 605 ft GRANITE
ft. ft. ( � t..,e y * I .
Sa.Well Location: ft. ft. I `fu t...
DAVID DEL SOL ft. ft. JUN 1 2 2024
Facility/Owner Name Facility 1D#(if applicable) ft. - ft.
323 AUBURN SKY TRAIL HENDERSONVILLE, NC ft. ft. if^ern-w4. , `-slr,. '""u
Physical Address,City,and Zip 21.REMARKS
HENDERSON 9519876409 THIS WELL WAS SELF- CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one Iatilong is sufficient)
N ,I 5-8-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): OPermanent or OTemporary 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: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 121 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: 605 (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(ci IOU) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 160 (ft.)
If water level is above casing,we"+" 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 firm 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
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.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