GW1-2021-01428_Well Construction - GW1_20210305

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only
1.W,ell Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPT1111
Nell Con[metor Name
2418 0 b• 125 Ft- 100gpm
n. I n.
NC N'cll Contractor C'enifcmion Number 15.OUTER CASING for multi<ased wells OR LINER ifa livable)
Greene Brothers Well & Pump, WT Inc. FROM T<1 DI{METER mCACFSS 11AIL I
0 f' 92 ft- 61/4 SDR21
C'ompam.Nome
WI20100118720 Ib.INNER CASING OR TUBING( eothermal closed-lao
2.Well Construction Permit N: FROM TO DIANIereR rmrKNEssI MATI:uIAI.
Lu'r nl7 applicnble well eonsrrverion perm.,li.e. WC.Cmarn,Smm. Fw...., m ft. ft. in.
3.Well Use(check well use): ft. ft. m.
Water Supply Well: 17.SCREEN
ii
FROM TO DIAMETER SLOT SIZE, Inc KNESS MAl'h1RIAL
❑Agricultural ❑Municipal Public fit. ft. in.
71Gcothemtal(Heating/Cooling Supply) ❑Residential Wznr Supply(single) ft ft. in.
❑Industrial/Commercial ORes'idential Water Supply(shared) 18.GROUT
:::hT1 L'allon =7Wells> 100.000 GPD FROM 10 MATERIAL E)I Pu ce%IENI{I ETR O Dd A N I Of NT
Non-Water Supply'A ell: 0 "' 20 1'- Bentonite
❑Monitoring ❑Recncery ft. ft.
Injection Well:
fit. fit.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa liable
❑Aquifer Storage and RecoA'ery ❑Salinity Barrier FROM TO NTERIAL EMPI-ACENIENT METHOD
❑.Aquifer Test ❑Slomlwater Drainage ft. ft.
❑Experimental Technology GSubsidence Control It. ft.
Geothermal(Closed Loopl ❑Tracer 20.DRILLING LOG otmich additional sheets if necessarsl
❑Geothemml(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I To I DESCRIPTION(ealoo haofaen ,.i L... e. tees:Im.e.c.I
0 11. 92 D Clay
4.Date Well(s)Completed: 01/28/21 W'el1ID4 92 f` 145 fit' Granite
5a.Well Location: t. ft.
Charles O'Neal ft. ft
Fii i,Iu,0wncr Mine 17a111ty IDa litappbcahle)
148 Serenity Hill Rd. Hendersonville 28792
Physical Address,City,and Zip ft' ft. { Hh
Henderson 0614167994 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
l itwell Geld one lag long is suffinemt 22.Certiftc on:
35.483 82.320
N " � � -1,->L Lk 1/28/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Nall(omractor Date
8, ignigg this @nm.I her fi,e'er,/,Char M trc/1(1 evs(a er el....trotted iu eamn4tnce a ith
7.Is this a repair to an existing well: GYes or '*No I-A AC.1C 02L 0100 or/51 NC IC 0:C o:nn II'ell Constrmtion Smndanis and omn a copy
Ifthis is a repair fill out Mtovt well consto"no t in/m'marian and"I"',die nature of the ofrhi,re.onl hag heee prmo ukd m rho, Jl o......
repair under#21 remarks se,uon or-on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hating the same You mac use the back of this page to pros ide additional well construction into
construction,only I GW-I is needed Indicate TO AL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary-
drilled:' _ 24.SUB?I IT I Al.INSTRUCTIONS
9.Total well depth below land surface: 145 (ft.)
For mtdaple ge l/s Up all depth.v /di/ferenr Iewmp/r 3(w200'nnr12(ti 100') Submit this GW-I within 311 days of well completion per the following:
10.Static water level below top of casing: 50 24a. For All Wells: Original tomb to Division of AA'alcr Resources OMR).
(ft Infomhation Processing Unit, 1617 MSC,Raleigh,NC"_7699-1617
If nmer/erel i,.above erring,use -
11.Borehole diameter: 6 1/4 (in.) 24b. For Injection Wells: Copy [o D\YR. Underground Iniection Control (IUC)
Program. 1636 MSC Raleigh.NC'_7699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return'A ells;('opy to the
li.e-auge,angry,cable,direct pmh,ac l county ern ironnhental health department of the count}'where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: C'up7 to DW'R.C'C'PC'U.A
13a.field(gpm) 100 Method of test, 2HOUrS
Perron Program, 1611 MSC.Raleigh,NC 2 7699-1 6 1 1
13b.Disinfection type: HTH Amount: 25 tabs
Form G W-1 North Carolina Depanaren[of Freiromnental Quality-Division of water Resources Revised 6-6-20 1 N