GW1-2022-00975_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
p ft- 305 ft. W.
2418
305 ft. 405 ft' seam 1 aosbas i¢om
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p I'L 89 ft. 1 61/4 in' SDR21
Company Name
JMQ-184W 16.INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Coumty,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industriaucommercial 13Residcntial Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. Bentonite
Monitoring DRecovery
Injection Well:
tt. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.
p ft. 89 ft, Clay
4.Date Well(s)Completed: 11/08/21 Well ID# 89 ft. 705 ft. Granite
5a.Well Location:
Jean Huttner
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
24 Escalante Rd Waynesville 28785 rt. rt. jAN 7 202?
Physical Address,City,and Zip ft. ft.
Haywood 8618-54-0798 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) =22rti :
35.566 N -82.984
11/08/21
6.Is(are)the well(s)oPermanent or Temporary Signatur of Certified We-IT-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 E)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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft•) 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: 200 (fl•) 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: hi 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,1Underground 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: 127 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