GW1-2021-01471_Well Construction - GW1_20210209

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 0 360 1/29pm
380 " 665 " 21/2gpm
NC Well Contractor Certification Number 15.OUTERCASING for mold-need weW OR LWER Ba tlnDle
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 " 42 " 61/4 Steel
Company Name 16.MCM-188W FR1NNERCASINGORTIWmAM eothermaelaed-too
2.Well Construction Permit�: FROM TO DIAMETER THICKNESSI MATERIAI.
List all applicable well construction permits(t.e.UIC Coun(v.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R, in.
❑Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 12.GROAT
❑irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 "' 20 "• Bentonite
OMonimring ORecovery
Injection Well:
R, h.
UAquifer Recharge []Groundwater Remediation
19.SANDIGRAVEL PACK n61e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG fiffliatch additional$beets If necessary)
❑Geothermal(Hearin Cooling Return) []Other(explain under#21 Remarks) mom I TO I DESCRIrTON colon hardness.wivroek t)W. rotin site.etc.
0 " 42 IClay
4.Date Well(s)Completed: 01/20/21 Wen ID# 42 "' 705 "' Granite
5a.Well Location: "• rt.
Tony King/Paul Belanger "• f.
Facility/Owner Name Facility lD#(if applicable) "• "•
1100 Panther Branch Rd Canton 28716 ".
Physical Address,City,and Zip "- "'
Haywood 8633-92-5521 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
0fwell field.one lat/long is sufficient) 22 erHfic on:
35.569 N 82.402 W 1/20/2021
6.Is(are)the wells): InPermanent or OTemporary Signature of Certified Well Contractor Date
At signing this form,I hereby Bert fivhat the we11(s)wus(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A h•CAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
If this is a repair,fill out known well constuction 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 bock ofthis farm.
23.Site diagram or additional well derails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well concoction info
construction.only I GW-I 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: 705 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3(a))200 and 2(d100')
Wells: Original form to Division of Water Resources (DW'R),
10.Static water level below top of rasing: 1 0 n ortna I a rocessing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level u above casing,use ` LL Lt�I
6 1/4 I L 2ab. m'eetion Wells: Copy to DWR, Underground Injection Control OUC)
11.Borehole diameter. (in.) X ogram, 636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary ..,,.Dn Pf
4&e%v*1gi4u 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) MR vmronmental 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
Permit Program, 1611 MSC.Raleigh.INC 27699-16l l
13a.Yield(gpm) `�1� L1 L1 Method of test: 2 Hours rs
13b.Disinfection type: HTH Amount: 127 Tabs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018