GW1--04725_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1•Well Contractor Information:
Taylor Ray Boger 'WATER ZONES
FROM 10 DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
15.OUTER CASING(for multi-cased bells)OR LINER(if applicable)
NC Well Contractor Certification Number
FROM TO DIAMETER 77ttt:1:NESS MATERI:tI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 n• 75 ft- 6.25 in. #21 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSS-2024-0 119 FROM ft. 10 ft. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO ' DI tMI:TER SLOT SIZE THICKNESS Si SI ERIAI.��
ft. ft. in.
❑Agricultural ❑Municipal/Public
—
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
( g/ 8 Pp Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GR00T
FROM I ark I ERLU, EV11'IACENIENI NM MOD&,1MOUNT
❑Irrigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FR061 TO MATERIAL EMPLACE:NF:Nl'METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier —
ft. ft.
DAquifer Test ❑Stormwater Drainage !t. ft,
❑Experimental Technology OSubsidence Control
—
20.DRILLiN (:(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.)
❑Geothermal(ileating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
6-26-2024 75 ft- 145 ft- GRANITE
4.Date Well(s)Completed: Well ID# it. ft•
5a.Well Location: ft. ft.
BILLYS MODULAR&MOBILE ft. ft AUG 1 2 2024
Facility/Owner Name Facility 11)k(if applicable)
130 RASPBERRY POINT LANE HENDERSONVILLE, NC
ft. ft.
I'ho.ical Address,City,and Zip 21.REMARKS
HENDERSON 10011321 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 tat/long is sufficient)
`N W %cr. A
Signature ofred e 626-2024
ell ntractor Date
6.Is(are)the wll(s): ©Permanent or ❑Temporary
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with/5.4 NCAC 02C.0i00 or 114 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ENo 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 42/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: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 24100') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ii.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 0 Method of test
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount ZO 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