GW1-2021-02417_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Rr 1_P*I '_- ,
Robin Webb ti s��✓'-"j ;""" `}
14.WATER ZONES
Well Contractor Name
_ FROM TO DESCRIPTION
I /�+
2418 0 fL 805 ft. yaew�
7 unit
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
D�Lin:cs'�CY;Cl1
Greene Brothers Well & PUMP, WT Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL 60 ft- 61/4 in' I SDR21
Company Name
N RH-244W 16.INNER CASING OR TUBING(geothermal closed-too
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): tt. ft, in•
17.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT NIET1I01)
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. R.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock tc pe,grain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) 0 ft. 60 IL Clay
4.Date Well(s)Completed: 05/21/21 Well ID# 60 tt• 1,605 tt• Granite
5a.Well Location:
Jim Lyons/Joanna Lyons ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Prestige Point Waynesville 28785 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8607-33-8391 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) 2�Z_o
on•
35.533 N 83.021 W
05/21/21
6.Is(are)the well(s)oPermanent or Temporary Signrtified 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: QYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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: 1,605 (ft.
P ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: 1,160 (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 A4 (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) 3/8 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: 291 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