GW1--06653_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD For internal rise ON'I.Y-
'f his form can 6c utsed for sicglc or multiple wells
I.Well Contractor Information:
Taylor Ray Boger i 14.WATERZONESI
FROM I TO I I I DESCRIPTION
Wei!C:nntrac or Name ft. I I I ft.
4614-A j ft. I I ft.
NC l+el!Cnn t actor Certification Number 15.OUTER CA LNGIffor-malt-i-cased wells)OR LINER(if applicable).
FROM I TO I' I DIAMETER I THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 185 j ' ft- i 6.25 in, #21 PVC
,1;;}.••,:me 16.INNER CASING OR TUBING(geothermal closed=loap►
OSS-2024-0496 i FROM ; TO , I DIAMETER I THICKNESS MATERIAL
2.Their Construction Permit;;=: ft. I I ft. ' in. I
1si1.:1!anpiien,nie well permits(i.e.County,State.Variance.injection.etc.)
ft. I I ft- in.
i
-.Well?:be(check well use): 17..SCREEN•
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS 1 \ia T ERh
ft- I ft. in
I
__.A._ricuitural ❑MunicipaliPublic 1
;7Ge:;thortnal •(l{eating Cooling Supply) •Residential Water Supply(single) ft. I fL in. I
=!Industrial Commercial ❑Reaidentiai Wax :IIGROUT •
y Supply(shared) FROM I TO I MATERIAL I EMPLACEMENT METHODS AMC
(:_1lr`ga'titln ft. ft
0 20 I Bentonite Pumped
Non-Water Supplh Well: I ! ,
:i tixritorins ❑Recovery ft. I. ft. Cap Top with Bentonite C
Injection Well: 1 ft. i 1, ft. ( j
❑Aquifer Recharge ❑Groundwater Remediation '.19.SAND/GRA ELIPACK(if applicable)
Ayu!fcr Storage and Recovery ❑Salinity Barrier FROM TO ' I M.ATERIAt. i EMPLACEMENT!METHOD
• ft. i ft
L)Ayuifer hest ❑Stormwater Drainage ft. ft. 1 1
DEnperimental Technology OSubsidence Control
20.DRILLLING;LOG(attach'adilitioeal sheets if necessam I
iGcothermal(Closed Loop) OTracer FROM TO ! I DESCRIPTION(color.hardoas.;nit/rock type.grain size.a
Geothermai(tleatingCoolingReturn) ❑other(explain under 421 Remarks) 0 ft. i$5 ; ft- i OVER BURDEN
9-23-202e1 85 ft, I225 1 ft. 1 GRANITE
4.bate Weil(s)Completed: Welt tail ! I ft' i ft.
5a.41'di Location: ,- ft. I ' ft. !
AMANDA MOSS I ft. i I. ft. i NOV 1 2 2024
`aciiir,Owner Name Facility[Dd(if applicable) I
o208aTERRY'S GAP ROAD HENDERSONVILLE, NC rt. i ft, I 11-eft :,., -'
ft. I
1 fr. I Lt,.`j: C.-0
ice.Ad;rtna.Cite.and Zip ,. .
..ZI:REy4AR1{S. .• i; • ...
HENDERSON THIS WELL WAS SELF CERTIFIED
Co^_m-, Parcel identification No.(PIN) i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 27•certification:
!ifv.•_i!fic!el.one intliona is sufficient) I
„ ; , j ' 9-25-2024
Signature of tr4r red Well ntractor Date
6.Is(arc)the Yett(S): Permanent or ❑"1 emporary 8y signing this form, 1 hereby ccr:( that the welts)was(were;constructed in,reco:
with 15.4 NC.4C 02C.0100 or III..1CAC 02C.0200 Well Construction Standards and
7.Is this a repair to an existing'well: ❑Yes or E No copy of this record has h'een provided to the nCli owner.
ll this is a repair.till am knoNTi well construction information and explain the nature al the
repair antler 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details of
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Foe multiple injection or non-water supper wells ONLY with the same construction.you can. I
submit one form. SUBMITTAL INSTUC[IONS
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9.Total well depth below land surface: 225 (ft.) 24a. For All Weils:I Submit this form within 30 days of completion of
For.melt p!e•.reds list all depths if different(ensamnle-2.2200'and 2(4100') construction to the following:
I
E 0-Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
:f t,nrer level'it come casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
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i I.Borehole diameter: 6.25 (in-) 2tb. For Injection\''ells ONLY: In addition to sending the form to the a,
ROTARY 24a above, also submit a copy of this Poem within 30 days of comp)etioi
12.Weil construction method: construction to the following:
.,. auger.rotary.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Progn
j FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I 6 RIG 24c,For Water Suppl &injection Wells:
13a_Yield(gpm) Method of test: I ie
PILLS Also submit one copy' (': this form within 30 dil,sof completion of
!3b.Disinfection type: Amount: 22 well construction to the county health department of the county'where
constructed.
Fort (,-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aug,