GW1-2021-06203_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 105 tt. 13gpm
ft. ft.
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
0 ft. 50 ft. 61/4 in- SDR21
Company Name '
MCM-266W 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.
3.Well Use(check well use): ft. ft. 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. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soittrock type,grain siu etc.
0 ft. 50 ft, clay
4.Date Wells Completed: 10/05/21 Well ID# 50 ft 205 ft.
() p Granite
Sa.Well Location: ft. ft.
David Spencer ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
227 Rocky Ford Dr. Waynesville 28786 ft. ft.
Physical Address,City,and Zip
ft. ft. 1
Haywood 8645-18-6132 21.REMARKS
nlAFM of—
County Parcel Identification No.(PIN) 1tiF
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.496 N -82.892 W ,
10/05/21
6.Is(are)the well(s) i Permanent or Temporary Signature of Certified 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: [3Yes or ®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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (it•) 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@I00') construction to the following:
10.Static water level below top of casing: 40 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 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) 13 Method of test: 2 Hours 24c.For Water Supply&Injection 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: afi rats 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