GW1--04726_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 ZONES
FROM To DE:SCltlrriON
Well Contractor Name ft. ft.
4614-A ft. ft.
NC Well Contractor Certification`dwnncr IS.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
FROM 11'0 DIAMETER THICKNESS MATERIAL
- CLYDE SAWYERS & SON WELL & PUMP INC +1 n• 70 ft• 6.25 in. #21 PVC
Company Name In.INNER CASING OR TUBING(geothermal closed-loop)
OSS-2023-0439 FROM TO DIAMETER fH/( NE SS MATEKI,U
2.Well Construction Permit#: ft. R. in. E
List all applicable will permits(i.e.County,State,Variance,Injection,etc.) I
n. ft. in. I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER- SLOT SIZE THICKNESS -_MATERIAL.
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply fr. ft- in.
( &' € PPY) PPY
❑industrial.%Commercial ❑Residential Water Supply(shared) a en 1T
FROM TO MA I ERtAL FMPLatEME:NI METHOD&AMOUNT
❑Irrigation 0 ft. ft. Bentonite Pumped
Non-Water Supply Well: 20
ft. ft. ,Cap Top with Bentonite Chip:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MAIERLO. F'SIrt_ACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft. i
['Aquifer Test ❑Stormwater Drainage
n. ft.
❑Experimental Technology ❑Subsidence Control — I
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock hpe.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 70 ft. OVER BURDEN
6-27-2024 70 ft- 185 ft. GRANITE
4.Date Well(s)Completed: ---Well ID# ft. ft. _
5a.Well Location: . �_"
ft. ft. i F^�a ti..4...r h.. ' �i...
BLUE RIDGE SKY PARTNERS
ft. ft. AUG 12CO24
Facility/Owner Name Facility fDk(if applicable) ft. R.
727 LYNDHURST DRIVE HENDERSONVILLE, NC - -_
--------- rt. ft. r.v::.s.c:' - t ;lt
�•
Physical Address.City,and Zip 2I.REMARKS
HENDERSON 9660005088 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 tat/long is sufficient)
N ,i (�H� ' 7-2-2024
Signature of ed ell ntractor / Date
b.is(are)the well(s): ©Permanent or ❑'Cemporary By signing this form.I hereby certify that the trell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®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 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: 1 85 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,[/erent(example- C3@200'and 2 100') construction to the following:
10.Static water level below top of casing: 25 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 15 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 2O 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