GW1-2021-02418_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 3Id N 1 0 qo�l 0 ft. 125
I L 1 5 fL iogm
4238 7 u111 ft. ft.
NC Well Contractor Certification Number Dr� q t,nrj"J11 15.OUTER CASING for multi-cased wells OR LINER if a ticable
Greene Brothers Well & Pump, WT Inc. vyy'`vim✓ FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 105 ft' 61/4 in. Steel
Company Name
SAS-122W 16.INNER CASING OR TUBING eothermal closed-loop)
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. R, in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g tt, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I
rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring Recovery
ection Well:quifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licablequifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test DStotmwater Drainage
xperimental Technology Subsidence Controleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.eothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
0 ft. 105 ft. Clay
ft. ft.
4.Date Well 06/02/21 s)Completed: Well 1D# 105 185 Granite
5a.Well Location:
Taylor&Janice Hughes
Facility/Owner Name Facility ID#(if applicable) ft. ft.
496 Stepping Stone Ln Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8624-19-9800 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) 22.Certification:
35.471 N 82.958 W
i 06/02/21
6.Is(are)the well(s)OPermanent or Temporary Si' ture of ertified ll ontractor 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 @No with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constr,t,tion 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: 185 (ft') 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I001 Construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
lfwater 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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: 33 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