GW1--04717_Well Construction - GW1_20240812

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.WATERZONES_FROM TO DESCRIPTION _
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER TFIICKNF:SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 55 ft. 6.25 in• #21 PVC
Company Name �+ r� �] 1S.INNER CASING OR TUBING(geothermal closed-Moo2.Well Construction Permit#: OJS-L024-OZH7 FR011 ft. TO ft. DIAMETER in. 1'ItICKNESS NI Al ERL\L
List all applicable well permits(i.e.County,State.Variance.injection,etc.)
-
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM _ f0 DIAMEI ER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public n ft. in.
❑
ti. ft. in.
❑Geothermal (Heating/Cooling Supply) lResidential Water Supply(single)
8
❑industrial/Commercial ❑Residential Water Supply(shared) ER'GROUT _
FROM r0 \IAIERIAI. F.SIPIAC F:MF:!'1 METHOD&.CM01iVI
❑hngatton 0 «. 20 it. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring El Recovery ft. ft Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATF:RIAI. EMPLACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. rt.
❑Aquifer Pest ❑Stormwater Drainage -
—
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil:rock tape,grain sin.etc)
❑Geothermal(lleating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 55 ft. OVER BURDEN
7-2-2�24 55 ft• 705 ft• GRANITE
4.Date Well(s)Completed: — -Well ID# ft. ft. • c -..
Sa Well Location: ,."'C••r a••,! s l i ft. ft.
STANLET LIVINGSTON ft. ft. c 2024
Facility/Owner Name Facility ID#(if applicable) ft.
382 JOHN DELK ROAD HENDERSONVILLE, NC 28792 :
" '.a
ft. ft. , , s '.�s`Y
Physical Address,City.and Zip 21.REMARKS
HENDERSON 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 lat/long is sufficient)
N W "'7—" 7-24-24
Signature of ed ell ntractor Date
6.Is(are)the well(s): WIPermanent or OTemporary
By signing this form,I hereby certify that the w ift's)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 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 421 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
A.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: 705 (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 et,200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (ft) Division of Water Resources,Information Processing Unit,
If water level cs above casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
it.Borehole diameter: 6'25 (in.) 2413.For Injection 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
13a.Yield m 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 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 Water Resources Revised August 2013