GW1--04720_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 14.WATER 2',ONES
FROM To DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number 111.`,Ol.AEA CASING(for multi-cased wells)OR LINER(if applicable)
FROM 70 DIAMETER THICKNESS _ MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 100 it 6.25 in. #21 PVC
Company Name ttr BASING OR TUBING(geothernud cto )
OSS-2024-0034 FROM Dt\ME'I'ER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
-
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: 'Root TO DI%METE:R SLOT SIZE 'rottKSESS M,vTFRISI.
ft. ft. in. -----
❑Agricultural ❑Municipal/Public
R. ft. iw•
DGeothermal(Heating/Cooling'Coolin Supply) ❑Residential Water Supply(single) I
❑IndustriahCommercial ❑Residential Water Supply(shared) t8.GROUT
FRUA1 "1
0 MATEICIAI- EMPLACEMEM1 1 ME:TIIOD&&MOBS"I.
❑Irrigation 0 ft• 20 ft. Bentonite Pumped
Non-Water Supply Well:
DMonitoring El Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 19.S.AND :I(AVEL PACK(if applicable)
FROM TO MATFR':AM, E\tri,\CE\I ENT%IETIIOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control -
20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 100 ft. OVER BURDEN
7-8-2024 100 ft- 705 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. r--
Sa.Well Location: ft. ft. S 3`�" •..°.. * "•L"f
EDWIN WELLS ft. ft. AUG 1 2 2024
Facility.%Owner Name Facility IDk(if applicable) ft. ft.
36 WHISPER MOUNTAIN ROAD HENDERSONVILLE,NC Ir,fs:: ,t,;:'^.7. i-t^. '41
ft. ft. WIC.i- i_•-.�
Physical Address,City,and Zip 21.REMARKS
HENDERSON 10011299 THIS WELL WAS SELF-CERTIFIED j
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 {� �/ 7-23-2024
Signature of ed ell ntra n Date
6.Is(are)the well(s): Iii Permanent or OTemporary By,signing this form,I hereby certify that the well(')was(were)constructed in accordance
with/5.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or El No copy of this record has been provided to the well owner.
11.this is a repair,fill out knolls?well construction information mid explain the nature of the
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 form. SUBiMI'I`I'AL INSTUC'f IONS
9.Total well depth below land surface: 705 (ft.) 24a. For AB Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3@:200'and 2 '100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 240 (ft.)
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the fonn 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:
t 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) 5 Method of test:
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