GW1-2021-08121_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bryant Smith 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 585 r' 590 ft.
2571 ft. f,
NC Well Contractor Certification Number '45—OUTER CASING r multi -LWER if cable)
:�i TO T DIAMETER I THICKNESS MATERIAL
Green River Well & Pump ft. r, in.
Company Name 16.110491K CASiNO-.-Oit•T-UBtNGlie6ibiriiaI c f6sed-lo-iiv)
WP 20-145 FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit 1 ft 60 rL 6 iO 21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 11 SCRFEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
M in.
OAgricultural OMunicipal/Public fL ft in.
DGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
Eltindustrial/Commercial 0 Residential Water Supply(shared) 'lucitouT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ' 20 IL Sakrete Mix&Pour
Non-Water Supply Well: ft. ft.
DMonitoring ORecovery
Injection Well: ft. ft
OAquifer Recharge OGroundwater Rernediation 19.SANDIGRAVELfACK(ifa6lkiblle)
DAquifcr Storage and Recovery OSalinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
DAquifer Test OStormwateT Drainage fL fL
ElExperimental Technology OSubsidence Control �20.,D1tlLtlNG2LCii,(],;(ittifilisiddifi6iii I daheejsifljoce I SSjirj)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION fcelay hardness,suil/rock type,grain sim etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 20 fL Red Clay
Sand&Water
4.Date Well(s)Completed: 2-12-21 Well 10# 20 fL 40 ft.
40 'L 50 ft. Shell Rock
5a.Well Location: 50 ft .605 fL Granite
JH Reaben Oil Co.
ft. M
Facility/Owner Name Facility ID#(ifapphcable) ft ft
3614 Hendersonville Highway ft. ft.
Physical Address,City,and Zip
21.REEMA]RkS- t;
Transylvania 77)
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.. NOV— 2021
(ifwell field,one tat/long is sufficient)
35 16 23 N 82 38 30 2115/21
W
Signature ofCerfifi6 I d IW81 I F Cbiltrictbi; Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or RINo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page;to provide additional well site details or well
8.Number of wells constructed: 1 construction details- You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 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 Reso i urces,Information Processing Unit,
Ifwater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: 'In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e-auger,rotary,cable,direct push,etc.)
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 30 Method of test. Air 24c.For Water Supply&Injection Wells
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county hei lth department of the county where
constructed.
I
Form GW-I North Carolina Department of FriNironment and Natural Resources—Division of Water Resources Revised August 2013