GW1--04722_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,WATER ZONES
FROST 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 or applicable)
FROM TO DIAMETER THI(KNF:SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 81 ft• 6.25 in* #21 l PVC
Company Name 1b.INNER CASING OR TUBING(geothermal closed-loop) ;
2.Well Construction Permit#• OSS-2024-0286 FROM ft. TO H. DIAMETER to THICKNESS MATERL\I.
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 DIAMEIF:R SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FRUM TO SMA I ERIAI. EMPI.\CEMF.NT ME-I HOD A.(1IOt1N1
❑Irrigation 0 ft' 20 rt• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FRO)1 Ii) NA'FERIAL FMPLA('ESf E.N F ME 1.110D
❑Aquifer Storage and Recovery ❑Salinity Bather ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary),
OGeothermal(Closed Loop) ❑Tracer FROM I l'O DESCRIPTION(color,kerdneys.soil/rock type.groin size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4,1 ft• OVER BURDEN
6-27-2024 81 ft. 445 ft. GRANITE
4,Date Well(s)Completed: Well ID# ft. ft. :. ". " -'
a '....
5a.Well Location: ft. ft. `A.....,�,.r i/ y,_,i,
PETER LADAS ft. ft: AUG 1 2 2024
Facility/Owner Name Facility IDk(if applicable) ft. ft.
143 ALLISON ROAD HENDERSONVILLE,NC 1r. ,:.,-r -• '--.:pa , . till
ft. ft.
Physical Address.City,and Zip 21.REMARKS
HENDERSON 9620583401 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 7-3-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ©Permanent or ['Temporary By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0/00 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0 No copy of this record has been provided to the well owner.
phis 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
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: 445 (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(1j200'and 2(d;100) construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,Information Processing Unit,
If writer level is above casing,use"*" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.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(gpm) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS 35 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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