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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER. THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0.0 ft' 50.0 ft• 2.0 ' in' SCH 40 PVC
List all applicable well construction permits(i.e.County,State,Variance.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public 50.0 ft' 55.0 ft' 2.0 '"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. R. in.
( � g PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.0 ft. 38.0 ft.
PORTLANDBENTONITE SLURRY
Non-Water Supply Well:
ft. ft.
tMonitoring ❑Recovery .
Injection Well: ft. ft.
DAquifer Recharge . ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
48.0 ft• 55.0 ft* 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ere.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft. 6.0 ft. BROWN/GRAY CLAY
01/05/22 MW-8S 6.0 ft. 30.0 ft. GRAY/BROWN SAND
4.Date Well(s)Completed: Well ID# 30.0 ft. 48.0 ft• WHITE/BROWN SAND
5a.Well Location:
KIMBERLY CLARK 48.0 ft' 55.0 ft' t RED/TAN PWR
ft. ft. I'
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR I
�Q29
401 BERKELEY ROAD HENDERSONVILLE 28792 /11C
ft. ft.
Physical Address,City,and Zip 21.REMARKS
HENDERSON BENTONITE SEAL-38.0-48.0 FEET. .., . .,..,
Coimty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/long is sufficient)
35° 20' 29.40" N 82° 28' 04.31" `� 01/13/22
Signature of Certified Well Contractor : Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: :Wes or MNo 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 I
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 farm. SUBMITTAL INSTUCTIONS :
9.Total well depth below land surface: 55.0 (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 a 200'and 2 ct/00) construction to the following:
10.Static water level below top of casing: 2.0 (ft.) Division of Water Quality,Information Processing Unit,
If stater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 8'0 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
AUGER 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 Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of WateriQuality Revised Jan.2013
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