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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 sr k
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. 5.0 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
❑Agricultural OMunicipal/Public 5.0 ft• 15.0 ft• 2.0 In' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.0 ft. 3.0 ft• PORTLAND BENTONITE SLURRY
Non-Water Supply Well: ft. ft.
0Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4.0 ft' 15.0 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) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0.0 ft- 6.0 ft• , BROWN/GRAY CLAY
01/05/22 MW-7S 6.0 ft. 15.0 ft. GRAY/BROWN SAND
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: ft. ft
KIMBERLY CLARK ft. ft. ' 's
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 1 4 2027
401 BERKELEY.ROAD HENDERSONVILLE 28792 ft. It.
Physical Address,City,and Zip 21.REMARKS
HENDERSON BENTONITE SEAL'3.0 4.0 FEET .
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35° 20' 29.60" N 82° 28' 02.74" �� J 01/13/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent 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 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 la the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under tt21 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 jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdijjerent(example-3@200'and 2@100) construction to the following: •
10.Static water level below top of casing: 2'0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 8.0 (in.) 24b.For Injection 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: f
(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&Injection'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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013