GW1-2021-02066_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb RECEIV L 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 it. 525 ft• sq ro
2418 J U L 0 'Ad 2021
NC Well Contractor Certification Number
11 formation Processing Unit 15.OUTER CASING for multi cased wells OR LINER if a licable
Greene Brothers Well & Pump, V nc- DV R Section FROM TO DIAMETER THICKNESS MATERIAL
0 f1. 89 ft. 61/4 in. Steel
Company Name
N RH-218W 16.INNER CASING OR TUBING eothermal 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.
Water Supply Well: 17.SCREEN
llp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0-1 Agricultural ®MunicipaVPublic [t. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. gentonite
Monitoring Recovery
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 �Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock t3,pe,grain size,etc.
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 g as ft• Clay
4.Date Well(s)Completed: 06/15/21 Well ID# 69 ft' 605 ft' Granite
5a.Well Location:
Seth McCleary
Facility/Owner Name Facility ID#(if applicable) ft. ft.
270 Mary Gray Dr. Clyde 28721 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8649-53-0804 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. rtifica'on:
35.595 N 82.888 W
06/15/21
6.Is(are)the well(s)[3Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert ,that the wells)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 constriction 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: 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: 120 (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) 1'5 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: 1os Tabs completion of well construction Ito 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