GW1-2021-06198_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
F
Travis Greene 14.A'VATER ZONES
Well Contractor Name FROM TO DESCRIMON
0 ft. 40 ft• .s ecm
4238 40 ft. 180, ft. e.eaPm l
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 TIHC.. MATERIAL
0 ft. 21 ft. 61/4 in. Steel
Company Name
GJ B-170W 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. in.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. rt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) -ft. ft. in.
IndustriaUCommercial 13Residentiai Water Supply(shared) I0.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• gentonite
Monitoring 13Recovery
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 DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 1 Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks 0 ft. 21 ft, Clay
rt.
4.Date Well 10/20/21 s)Completed: Well ID# 21 205 ft. Granite
ft. ft.
5a.Well Location:
Doug Crawford
Facility/Owner Name Facility ID#(if applicable) ft. ft.
505 Campers Ln Canton 28786
Physical Address,City,and Zip ft. ft. O V I
Haywood 8662-57-6423 21.REMARKS
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.Certification
35.414 N -82.809 W ,
J,�,,,� 10/20/21
6.Is(are)the well(s)OPermanent or 13Temporary 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 ONo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known we//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 I 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: 205 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 A (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) 5 Method of test: 2 Hours 24c.For Water Supply&Infection 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: a6 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