GW1-2021-00602_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 0 1205 1/29Pm
205 ft 465 ft 1/2gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER TH1cw" MATERIAL
Company Name 0 ft. 168 ft- 61/4 in. I ISDR21
W E L2020-00419 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIUCKINESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
❑Monitoring ❑Recovery ft. ft.
Injection Well: tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control R. It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 rt. 68 rt. Clay
4.Date Well(s)Completed: 01/1 1/20 Well ID# 68 f`' 525 ft Granite
5a.Well Location:
rt. rt.
Ben Makohon ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
160 Paynes Country Ln 28803
Physical Address,City,and Zip
Buncombe 9666-50-8895 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or� �� /C
(if well field,one lat/long is sufficient) �/ C erdf aHon
35.516 82.475
N2 6 1/11/2021
6.Is(are)the well(s): OPermanent or ❑Temporar Signature of Certified Well Contractor Date
I f;' SIP iation Processlnq Ug It g this form I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or [INo DWR Section 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100)
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use
f Stack water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
1
6 1/4 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)1.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: Hours
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:96 Tabs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018