GW1-2022-01617_Well Construction - GW1_20220203

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 265 ft. log"
2418
rt. 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. 108 ft' 61/4 in. SDR21
Company Name r�
ZOZ 1-21791-9-11431 16.INNER CASING OR TUBING eothermal closed-loop)
2.W¢II 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): It. tt. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. rt. in.
18GROU
Industrial/Commercial Residential Water Supply(shared) . T
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• sentonite
Monitoring 13Recovcry
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater 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 DESCRIPTIONcolor,hardness,soil/rock type, rain sim,etc.
0 ft. 108 ft, Clay
4.Date Wells Completed: 01/18/22 Well ID# 108 fL 305 ft,
p Granite
5a.Well Location:
Burton &Joann Marshall
Facility/Owner Name Facility ID#(if applicable) ft. ft
91 Granite Rock Rd. Syvla 28779 ft. ft. e
Physical Address,City,and Zip ft. ft. Lo U3 20[-)
Jackson 7683-04-1401 21.REMARKS
County Parcel Identification No.(PIN) 4 PPF--
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. tific tion•
35.425 N -83.096 M
01/18/22
6.Is(are)the weU(s)OPermanent or 13Temporary tgnatu oTtertified 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 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: 305 (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@100') construction to the following:
10.Static water level below top of casing: 60 (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 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) 10 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: ss 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