GW1-2021-02067_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:Tad Thompson fRE-GEN
ED 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 2�21
p ft. 120 ft. as
4364 J U L
1 0 ft. 380 ft' 2.5
NC Well Contractor Certification Number rlfGfn'3t20I1 processing 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT I�(:. ovVR Sedan FROM TO DIAMETER THICKNESS MATERIAL.
0 ft. 84 IL 61/4 in. SDR21
Company Name
N RH-259W 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
NGeothermal(Heating/Cooling Supply) OResidcntial Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
brigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
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 [3Stormwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiUrock q rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 84 ft- Clay
4.Date Well(s)Completed: 06/29/21 Well ID# e4 ft. 465 ft.
Granite
5a.Well Location: it. ft.
Lowell Ball ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
49 Eddies Trail Waynesville 28785 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8619-62-1606 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) , 22.Certification:
35.588 N 82.983 W `
nmc 06/29/21
6.Is(are)the well(s)OPermanent or Temporary Signature o Certified Well Con a or - Date
By signing this form,I hereby certify that the wcll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 br 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: 465 (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 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: 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) 6 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: 85 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
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