GW1-2021-00442_Well Construction - GW1_20210201

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 404.YWATERaZONES
Well Contractor Name FROM TO DESCRIPTION
3287-B 5
ft. ft.
NC Well Contractor Certification Numb" 15,OT)TER,GASING formnlh cased)
s %""' 4& `uwells OR1LtINEIt,'I lice"b! . ' _"u
I ET FROM TO DIAMETER THICKNESS MATERIAL
ft.
i.
Company Name
1"6.404NERIGASINGM114 INGT`e-5iW4 rmal1c]ds ded=loo ;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 fL 5 ft 2 in' Sch40 PVC
3.Well Use(check well use): ft' & im
d17!ISGREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 5 ft 15 ft- 2 in- 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) th ft in,
Industrial/Commercial Residential Water Supply(shared) 1S.KGROUT
711rrigation FROM I TO MATERIAL .EMPLACEMENT METHOD&AMOtWTr
Non-Water Supply Well: 3 ft 4 ft Bentonite Poured/25LB
Monitoring DRecovery 0 ft 3 ft- Cement Poured/60Lb
Injection Well:
ft. ft
Aquifer Recharge 13Groundwater Remediation 9SAND/GRA1sEIfaP GKt if a lice ta bIf
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 4 fL 15 ft #2 Sand Poured
Experimental Technology 13Subsidence Control ft &
Geothermal(Closed Loop) 13Tracer 20QDRIL•LINGIIOG1"aimch7addi6onglsheltsif.n s
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) FROM TO DESCREMON color,hardness,soufmk type,grain size etc.
See Consultant Log
4.Date Well 1/25/2021 s)Completed: Well ID#MW-1 ft ft.
5a.Well Location: & &
Former Stonetree Aussies ;�c +,=- J,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. a
340 Greenville Hwy ,Brevard 28712 ft ft
Physical Address,City,and Zip & ft
Transylvania2t1tE111ARK5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
35 13 31.20 N 82 43 26.80 W 1/28/2021
6.Is(are)the well(s) x Permanent or Temporary Signature ertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or Jallo with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 (fk) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:7 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+'. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.$ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016