GW1-2021-02069_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i '
Tad Thompson DECE��I 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4364 J U L 0 u 202+1 N/A ft• N/A rt. wA
rt. rt. I
NC Well Contractor Certification Number P
rrration Processing Unit 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, V nc.DWR Sedon FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 22 ft' 61/4 in. SDR21
Company Name
MCM-239W 16.INNER CASING ORTul3ING eothermalclosed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) rt. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ii.
IndustriaUCommercial 13Residen6al Water Supply(shared) l8.GROUT
Irfi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. Bentonite
Monitoring Recovery ft. ft.
Injection Well:
fL 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 13Subsidence Control
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Geothermal(Closed Loop) 13Tracer 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,gmin size,etc.
0 ft• 22 ft• Clay
4.Date Wells Completed: 06/17/21 Well ID# 22 ft• 865 ft.
p Granite
5a.Well Location:
Thomas Kolaski
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
345 Moorehill Dr Waynesville 28786
Physical Address,City,and Zip
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 82.884 ,
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N w \ hb�f (C"v 06/17/21
6.Is(are)the well(s)OPermanent or Temporary Signature ofCertified W ll Contractor � Date
By signing this form,1 hereby certif,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or I5A 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: 885 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: N/A (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) N/A 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: 1sz Tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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