GW1--04723_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 14.WATER ZONES
FROM 'rO DES(RlrrtO,
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 THICKNESS MATERIAL ___
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 125 R• 6.25 in* #21 PVC
Company Name r :.,i.5..v SING OR TUBING(geothermal dosed-loop)
OV CJ,�;�o FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Pern..... 2.3- �,11 ft. ft. in.
List all applicable well permits(Le.County,State,Variance,Injection,etc.) R. R. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO utAMFI ER Sf1)T SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
( �` 8 PP Y) PP y
❑Industrial/Commercial ❑Residential Water Supply(shared) 113.GROUT
FROM TO MATERIAL I.MI'L1t 61tF7\T MS..11i011 A tMUUA I
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. R. Cap Top with Bentonite Chips
Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _t9.SAND(GILIVEL PACK(if applicable)
FM)M ro SIATFRIAI. F:MtLACEMENT%IETIIOD
❑Aquifer Storage and Recovery OSalinity Barrier - —
ft. ft.
❑Aquifer Test ❑Slormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach addition,lsheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,kardeess.soiFrock type.grain sire.etc.)
❑Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) 0 ft 125 R• OVER BURDEN
4.Date Well(s)Completed: 7-1-2024-Well ID# 125 ft• 185 n• GRANITE
R. ft. _ _ J{
5a.Well Location: :• •,..i L.)
R. R. . `s ti.`,..0 a.. 4...
REMIGIA ESPINOSA ft. ft. AUG 1 2 2o24
Facility/Owner Name Facility Mk(if applicable) ft. R.
91 CARROLL MOUNTAIN DRIVE HENDERSONVILLE ..,,.,.• +
_ ft. ft.
Physical Address.City,and Zip 21.REMARKS
HENDERSON 951 9726334 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
N ,` 7-2-2024
Signature of ed ell ntractor Date
6.Is(arc)the wea(s): ©Permanent or DTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or I SA 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.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder 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.your can
submit one form. p C SUBMI tTAL INSTUCTIONS
9.Total well depth below land surface: 1 85 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-4'4200'and 2@100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of easing: 30 (ft)
If water level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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:
lie.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) 1 O Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 well construction to the county health department of the county where
_ constructed.
Form(iW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013