GW1--04728_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD For Internal Ilse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Taylor Ray Boger _14.WATEItZONES
FROM '10 DESCRIPTION
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 THICK NESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 137 ft• 6.25 in. #21 PVC
Company Name (i.INNER I.ASINt�OR'LURING(geothermal closed-loop)
OSS-2024-0259 FROMDIAMETER THHCKNESS MATERIAL
2.Well Construction Permit#: ft. R. in.
List all applicable well permits(i.e.County,State,Vw'iance.Injection,etc.) ft, - ft. in.
3.Well Use(check well use):
Water Supply Well• FROM To DD\FTF.R _SI OT SIZF THICKNESS NI:1 FERIA i.
❑Agricultural ❑Municipal/Public ft fl. n.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) R. ft• 'rr•
( g D' PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM f0 MATERIAL F NI PT NCEMEN I METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chip:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL FNIPLACENIEN1 METHOD
❑Aquifer Storage and Recovery ❑Salinity Battier
(1. ft.
❑Aquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control
—
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,bordness.soil/rock hype.groin size,etc.)
❑Geothermal(Ileating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 137 ft. OVER BURDEN
5-30-2024 137 ft- 545 ft. GRA E,
4.Date Well(s)Completed: --Well ID#
ft. It. �..
V �..'l�.r'.
Sit.Well Location:
ft. ft.
CODY HENSON ft ft AUG 1 22024
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1Gt:a:>.14.i`c; --••
347 BALD ROCK ROAD HENDERSONVILLE, NC 28792 `,
O
ft. ft. r:•t• '
Physical Address,City.and lip 21.REMARKS --
HENDERSON 1001 1 17 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 let/long is sufficient)
N `,i, 6-13-2024
Signature of led ell ntractor Date
6.Is(are)the well(s): PtPermanent or OTemporary By signing this form,1 hereby certify that the uell(s)was(were)constructed in accordance
with 15.4 VCAC 02C.0100 or 114 1NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
(/this is a repair,fill out known well construction information mid 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. C c SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 545 (ft.) 24a. For All Wells: Submit this form within 30 days of'completion of well
For multiple wells list all depths ifdi_(ferent(example-3@200'and 4000') construction to the following:
10.Static water level below top of casing: 70 (ft.) Division of Water Resources,Information Processing Unit,
if 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:
t(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:
I3a.Yield(gpm) 1 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 OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013