GW1-2021-03476_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 80 ft' 311.m
4238
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Hcable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 25 ft. 61/4 in. SDR21
Company Name
2021-20645-9-10733 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) tt. ft. in.
3.Well Use(check well use): tt. ft. in.
17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [1 Municipal/Public ft. ft. I in.
Geothermal(Heating/Cooling Supply) OResidcnfial Water Supply(single) fL ft. in.
Industrial/commercial 13Residcntial Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o tt 20 tt Bentonite
Monitoring rlRecovery
Injection Well:
lGeotAquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
hermal
Experimental Technology [3Subsidence Control Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessa(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack e, rain size,etc.
p ft. 25 ft, clay
4.Date Well(s)Completed:04/27/21 Well ID# 25 ft. 185 ft, Granite
5a.Well Location:
Tamera Crisp/Billy Brede
Facility/Owner Name Facility ID#(if applicable) ft. ft. .
• ,t
757 Calvary Church Rd Sylva 28779 ft. ft. 021
Physical Address,City,and Zip ft. ft. i ut1�t
Jackson 7539-27-0943 21.REMARKS Iov
OII's r r,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.318 N 83.251 W
04/27/21
6.Is(are)the well(s)o—Permanent or Temporary Sigdature of Certifie ell 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: ®Yes or MNo with 15A NCAC 02C.0100 or 15A 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 Geoprobe/DPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsolattach additional pages if necessary.
drilled:-' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 80 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary 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.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: 2 Hours 24c.For Water Supply&Iniection 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: HTH Amount. completion of well construction to'.the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016