GW1-2021-02423_Well Construction - GW1_20210615

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 ft. 405 ft. sagwo
2418
NC Well Contractor Certification Number T t 4 15.OUTER CASING for multi-cased wells OR LINER if a livable
Greene Brothers Well & Pump, W I InC�ly FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 68 It- 61/4 in. SD1221
P Y .^rill Y C^L,nES31i7
SAS-15819111I'" ^I;�31 16.INNER CASING OR TUBING eothermal closed-loop)
I. s"u� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I��+i�r�"
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.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring Recovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACENI ENT NI ETHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Traeer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock t� e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
0 ft. 68 ft. Clay
4.Date Well(s)Completed:05/18/21 Well ID# 68 ft. 445 ft. Granite
Sa.Well Location: ft. ft.
Janine Lennox/Steve Bernardi rt. ft.
Facility/Owner Name Facility ID#(if applicable)
252 Runaway Hill Dr Waynesville 28786
Physical Address,City,and Zip
Haywood 8625-97-2204 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Mlo
35.492 N 82.931 W
05/18/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified We ontra or 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: OYes or ONo 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#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:_1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 445 (fl•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-II3,@,200'and 2@100) construction to the following:
10.Static water level below top of casing: IILO (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 A (in,) 24b.For Infection 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.)
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: 81 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