GW1-2021-02068_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Tad Thompson 14.WATER ZONES
Well Contractor Name - FROM TO DESCRIPTION
0 It. 300 ft. 30.gpm
4364 J U L O 2 2021 ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT p rn;ati0n Processing U FROM TO DIAMETER THICKNESS MATERIAL
la1,NR Sect i n 0 ft. 28 ft' 61/4 SDR21
Company Name
MCM—r104W 16.INNER CASING OR TUBING(geothermal closed-loop)
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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 R. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in I
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. sentonite
Monitoring 13Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if a licable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACE1iF,NT METHOD
Aquifer Test 13Stormwater Drainage ft. tt.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock F rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 28 ft. Clay
4.Date Well(s)Completed: 06/21/21 Well ID# 28 ft 325 ft.
Granite
5a.Well Location:
Thomas Kolaski
Facility/Owner Name Facility ID#(ifapplicable)
345 Moorehill Dr Waynesville 28786 it• ft.
Physical Address,City,and Zip ft. ft.
Haywood 8645-48-1937 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.Certification:
35.499 N 82.884 M
06/21/21
6.Is(are)the well(s) Permanent or Temporary Signature of Certified ell Con actor 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: [3Yes 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 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-I 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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) 30+ 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: fio 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