GW1--04724_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal I!seONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger :'4.WATERZONES
FROM '1-O DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification Number ' 7:f+(for multi-cased welts)O (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 136 ft. 6 1/8 tn. #188 STEEL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
OSS-2024-0222 FRO
2. DIAMETER rlr(KNESS wnTERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(Le.County,State.Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use): 7.SCREEN " e -, k,
Water Supply Well: FROM TO IR%MI'I ER SLOT SI7.F THICKNESS - MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
B. ft. in.
❑Geothermal (Heating/Cooling Supply) ElResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FRO�1 r0 MA't F:RIAI. TM PI, C.EMEIN ME;FliOli A AS101IVI
❑Irrigation 0 tt_ 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chipt
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
twist TO MAI FRIAl. EMPLAC[M ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control .w .,
20.DRILLING LOG(attach additional sheets if necessary) ,, ,-,,k'Z
OGeothermal(Closed Loop) ❑Tracer FROM O DESCRIPTION(color,hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 136 ft- OVER BURDEN
4.Date Well(s)Completed: 6-26-2024 136 ft. 405 ft. GRANITE
Well ID#
ft. ft.
5a.Well Location: ft. rt. R .+-- ' ., !ti,7 f
CARL STRICKLAND ft. ft. AUG 1 2 2024
Facility/Owner Name Facility 1D4(if applicable) ft. ft.
APPLE COUNTRY ESTATES LOT 15/16 HENDERSONVILLE ft. fr. ll ---- ;' �i uiTy
Physical Address,City,and Zip 21.REMARKS : ,• f...i
HENDERSON 9936240 THIS WELL WAS SELF-CERTIFIED j
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 7-2-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,l hereby certi that the sell(s)was(wire)constructed in accordance
with 15.4 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 EINo 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#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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3(42 (400'and 1 /00) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
1If water level is above casing,use"," 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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:
ti.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