GW1-2021-03074_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION 1
Well Contractor Name
2418
p ft. 265 ft. z9Pm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER, THICKNESS MATERIAL
p ft. 57 ft. 61/4 ' in J SDR21
Company Name 16.'INNER CASING OR TUBING Qothermalpclosed-loop)
2.Well Construction Permit#: AKJ-449W FROM TO I DIAMETER I 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.
' ,
i"Irrigation
ater Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS _MATERIAL
Agricultural ®Municipal/Public ft. ft. in.;
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. in.
ndustrial/Commercial [3Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. gentonite
Monitoring _ Recovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL 9 EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets"if necessa
FROM TO DESCRIPTION color,hardness soil/rock a rain size,etc.)
Geothermal Heating/Cooling Return) _ Other(explain under#21 Remarks) p ft. 57 ft. clay
4.Date Wells Completed: 03/05/21 Well ID# 57 ft. 305 rt
p Granite "
5a.Well Location:
Kathy& Raymond Joseph rt. ft. .a, pa •�"'a
Facility/Owner Name Facility ID#(if applicable) ft. ft. "
1829 Sacred Cove Dr Clyde 28721
Physical Address,City,and Zip ft. ft.
Haywood 8743-13-5053 21.REMARKS ��, >t Cot;c.y.•t.
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 ertitiC on
35.703 N 82.901 W
03/05/21
6.Is(are)the well(s)oPermanent or Temporary Signature fCerti ed Well Con actor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes 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 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: 305 (ft.) 24a. For All Wells: Submit this form wit in30 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 Resou Ices,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Cer ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Infection Wells: In addition to se I ding 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) 12 Method of test: 2 Hours 24c.For Water Supply&Iniectio"n 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: 56 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