GW1-2021-01719_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb 14,WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
2418 p ft. 265 ft• mom I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells 0 I LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 42 ft' 6114 in. SDR21
Company Name
N RH-226W 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.) ft. ft. in.
3.Well Use(check well use): ft. ft. a in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. im
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 6entonite
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL T EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRn'TION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) 0 ft. 42 ft, Clay "
4.Date Well(s)Completed:03/16/21 Well ID# 42 ft 505 ft• Granite"
5a.Well Location:
Larry Greene
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lot 4 Adcock Mountain Rd Waynesville 28785
Physical Address,City,and Zip
Haywood 7790-44-8634 21.REMARKS 1Zi
County Parcel Identification No.(PIN) ^i4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. Ica 'on: M
35.619 N 83.056 W IC
03/16/21
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certified Wcll Contractor I Date
By signing this form,I hereby certify that the well(s)was(were)constructed to accordance
7.Is this a repair to an existing well: ®Yes or E]No 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 constriction information and explain the nature of the copy of this record has been provided to the well dwner.
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 J
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9.Total well depth below land surface: 505 (ft•) 24a. For All Wells: Submit thiis'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service I Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (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(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,iRaleigh,NC 27699-1636
13a.Yield(gpm) 3 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: s2 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 Resourc es Revised 2-22-2016