GW1-2021-06197_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4238 o rt. 40 ft. 59Dm �
40 ft- 500 ft. s9Dm
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. 21 ft' 61/4 I in. Steel
Company Name
MCM-284W 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. rt. in.
SCREEN17.
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 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. gentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness soil/rock e, rain sin,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
ft. 21 IL Clay
4.Date Well(s)Completed: 1,0/19/21 Well ID# 21 tt 525 rt Granite
ft. ft.
5a.Well Location:
Campbell Cauthen
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
33 Horse Cove Rd. Canton 28716 rt. rt.
Physical Address,City,and Zip ft. ft. 9
Haywood 8662-56-6831 21.REMARKS Ali
L
County Parcel Identification No.(PIN)
IfUp ECTION
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SS1NG Ul
(ifwell field,one lat/long is sufficient) 22.Certification:
35.413 N -82.807 W ,
_ ._ 10/19/21
6.Is(are)the well(s)[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: ®Yes 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#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: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 10 (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 Injection 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) 2 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: ss Tabs completion of well construction to the county health department of the county
where constructed.
Fomi GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016