GW1-2021-01831_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
gp �1`� 0 ft. 80 ft. ao9om
2418 fYJ a
rt. rt.
NC Well Contractor Certification Number M Q 1 V 3 2021 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. 1 P FROM TO DIAMETER' THICKNESS MATERIAL
.q"An U ft. 20 ft.
6114 in. SDR21
Company Name N//4 1lryf G[Ir3DwR 5t3CrpC1 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
IN
ter Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural ®Municipal/Public ft. R, in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
ndustrial/Commercial ®IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 tt. 20 ft. Benlonite
Monitoring ®Recovery
ection Well:
quifer Recharge [3GroundwateT Remediation
19.SAND/GRAVEL PACK if applicable)
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test [3Stormwater Drainagexperimental Technology OSubsidence Controleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color,hardness,soiVrock e, rain sire,etc.eothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 1 0 ft. 20 ft, Clay
4.Date Well(s)Completed: 04/02/21 Well ID# 20 ft• 105 ft• Granite,
ft. ft.
5a.Well Location:
Bob Turner
Facility/Owner Name Facility ID#(if applicable) ft. ft.
330 Avery Creek Rd Arden 28704
Physical Address,City,and Zip ft. ft.
Buncombe 9623-89-6432 21.REMARKS
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. rtif ation•
35.452 N 82.597 W
04/02/21
6.Is(are)the well(s)�IR Permanent or Temporary Signature of Cert fied 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: DYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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#21 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 also attach additional pages if necessary.
drilled:-' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 105 (II-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
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10.Static water level below top of casing: 3 (ft.) 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.) 246.For Iniection Wells: In addition toy 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: If
(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
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13a.Yield(gpm) 40 Method of test: 2 Hours 24c.For Water SUDDIV&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: 18 Tabs 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
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