GW1-2021-05252_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418
0 ft. 805 It. 12gM
`
ft. rc. I
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER it a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 47 ft' 61/4 in. SDR21
Company Name
W P20-128 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. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural � /Pu Municipalblic tt. ft. in•''
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. 9entonitei
Monitoring C3Recovery ft. rt.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage
Experimental Technology Subsidence Control
I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks)
0 ft. 47 ft• Clay
4.Date Well(s)Completed: 04/09/21 Well ID# 47 ft• 825 ft.
Granite
ft. rc.
5a.Well Location:
Carl & Lois Ganner
Facility/Owner Name Facility ID#(if applicable)
11614 East Fork Rd Brevard 28712 rt. rL VNI a k_.1 5r� '
Physical Address,City,and Zip ft. ft.
Transylvania 8562-16-2356-000 21.REMARKS
County Parcel Identification No.(PIN) f.,r„ lt� P ores,. irl Unil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Qd"ifR aEc�I!Oi1
(ifwell field,one lat/long is sufficient) 22.C fi tion•
35.136 N 82.807 w 04/09/21
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified-Well Contrac 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: [3Yes 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 ofthe copy ofthis record has been provided to the well owner.
repair under#11 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: 825 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3I@200'and 2@I00') construction to the following:
10.Static water level below top of casing: t O- (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 1/4 (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) 12 Method of test: 2 Hours 24c.For Water Suaaly& 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: 151 Tabs completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016