GW1-2021-01473_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Nall Contractor Name
2418 0 b- 225 40gpm
ft. ft.
NC V,'ell Contractor Certification Number 15.OUTER CASING for multicased wells OR LINER if a &able
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER HIC KNESS MLATERTM
Company Name 0 ft 20 ft 61/4 i SDR21
NRH-198W 16.INNER CASING ORTUBINC eothermalclmed-too
2.Well Construction Permit#: FROM TO DLAMIETER 'rH1eKNESsI MATERIAL
List all applicable well construction permits li.e. OF Coanrt.Stare_Inrimire,etc ft. ft. in.
3.Well Use(check well use): n, ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNlsS MIAI'F.RIAL
�Agoculmml El Municipal!Public D. ft.
OGeothemtal(Heating/Cooling Supply) OResidential Water Supply(single) n. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
'_1Inlgalmn ❑Wells> 1040(101iPD FROM TO MATERIAL EM PL ACEMIENT METHOD d AMOU Nr
Non-Water Supply Well: 0 f6 20 " Bentonite
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
ElAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK
❑ ft Iteable
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MA'1'Em AT EMPLACEMENT METHOD
❑.Aquifer Test ❑Starmwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothemud(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
06eothemral(Heating/Cooling Remm) ❑Other(explain under b21 Remarks) FROM I 'to IoeseRlenoN(ronv.namasu.saivrarKn e. ra .e,efe.l
0 22 "• Clay
4.Date Well(s)Completed: 02/1 9/21 We111D# 22 " 245 "• Granite
Sa.Well Location: ft. ft.
John Daily/Clyde Mtn. Properties R, f.
Ftulay Owner Name Facility ID,lit applicable) "' ft.
Triple Creek Dr. Clyde 28721 ft. it.
Physical Address,City,and Zip ft. It.
Haywood 8741-55-0277 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one lat'long is sufficient) 22.Certifle tion:
35.653 N 82.889 W.
���,� 2/19/2021
6.IsOre)the well(s): LPermanent or ❑Temporary Signature ofCenified Neu Contractor Dam
to signing this form.I hereby rest n than the,vell(s,,was(were)cmesn..wain uooardnnre with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NC'AC 02C 010( or 15A NGIC 02( 0'00 x'ell Consto,,noo Standards and that a eopv
Jrhu is a repair,Bfl our knmvt well cansrruatlon inlormalion and e_rplain the nature afthe of this rrrord hac been provided ro tint xrll mvner.
repair under a 21 remarb section or on the bark o/this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sarne You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
dolled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft.)
For nndrlple+Dells list al/depths o,dater,,,(b,,,onple-36,209'and:=100') Submit this GW-I within 30 days of well completion per the following:
80 24a. For All Wells: Original fonn to Division of \\rater Resources (DN'R).
10.Static water level below top of casing: (B') Infomtation Processing Unit. 1617 MSC Raleigh,\C 27699-
q+caner level is above caring.use - g 1617
11.Borehole diameter: 6 1 A (in) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program. 1636 MSC Raleigh,INC 2 7699-1 63 6
12.Well construction method: ROtary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(I-e.auger,mtary.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 C'CPCUA
13a.Yield(gpm) 40 Method of test: 2 Hours
Permit Program, 1611 MSC.Raleigh.NC 2 7 699-1 61 1
I3b.Disinfection type: HTH Amnnnh 43 Tabs
Form G W-1 North Carolina Department of Lnviroomental Quality-Division of N'ater Resources Revised 6-6-201 R