GW1-2021-01426_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
Well Contractor Name
0 185 18gpm
2418
n. n.
NC Well Contractor Cenificitnon Numher 15.OUTER CASING(form wells OR LINER it liable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 93 m 61/4 SRD21
Company Name p 16.INNER CASING OR TUBING eothermal elmed•loo
2.Well Construction Permit#: W 120100 1 1 5863 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructom permits lie.UIC,Cause,Stale. farionce,etc) ft. R. in.
3.WeB Use(check well use): ft ft, in.
Water Supply Well: 17.SCREEN
FROM I TO DLAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) n. p, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrl anon ❑Wells> 100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 20 ft• Bentonite
❑Momtoring ❑Recovery n. n.
Injection Well:
n. rt.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a able
OAquifer Storage and Recovery [-]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrawater Drainage fL R
❑Experimental Technology []Subsidence Control n. ft
OGemhermal(Closed Loop) ❑Tracer 20.DRILLING LOG am additioml sheets if neeessa
OGeothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRI"ION(color,hivxhv .wit ruck ov a ou,ern.)
0 f` 93 t` Clay
4.Date Well(s)Completed: 02/01/21 Well ID# 93 h' 205 n• Granite
5a.Well Location:
Heather Rodriquez/Chds Sizemore
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
2926 Old Clear Creek Rd. Hendersonville 28792 D• p• , X
Physical Address,City,and Zip n. ft.
Henderson 9692-73-8946 21.REMARKS
County Parcel Identification No.IPIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Cerfific .
35.418 N 82.364 W e�� 2/1/2021
6.Is(are)the weins): OPermanent or ETemporary Signature of Certified Well Contractor Dale
to signing this form,I hereby certift that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or n No I5A NCAC 01C.0100 or I5A NCAC 01C 0200 Hell Construttian Standards and that a copy
/f this is a repair,fill out known well constriction myornmrion and explain the nature of the of this record has been provided to the well owner,
repair under rr11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional "ell 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 if necessary.
drilled:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifdi/ferent(evample-3(�a 200 and 2(a100)
24a. For All Wells: Original font to Division of Water Resources (DWR),
If venter level is above causing,use"-
10,Stack water level below top of casing: 40
lf tion Pro t,) Informacessing Unit, 1617 MSC,Raleigh,NC 2 7699-1 6 1 7
"
11.Borehole diameter: 6 1/4 (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Wet]construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
0 c.auger,rotary,cable,direct push,etc I 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
13s.Yield(gem) 1U
o Method of test: 2 Hours Permit Program, 1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type: HTH Amount: 36 tabs
Form GW-1 North Carolina Department of Environmental Qua[try-Division of Water Resources Revised 6-6-2018