GW1-2021-02070_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: x
1.Well Contractor Information:
Robin Webb DECEIVED 14.WATER ZONES
Well Contractor Name �^ q q{ FROM TO DESCRIPTION
0
2418 J U L O u 20 L I ft. 485 12gp.
rt. rt.
NC Well Contractor Certification Number 9 t)nit
Greene Brothers Well & Pump, WfigjfGI.n''atlon processing 15.OUTER CASING for multi-cased wells OR LINER if a livable
p\ R SedOn FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 43 IL 61/4 in. Steel
Company Name
N RH-2rJ7W 16.INNER CASING OR TUBING geothermal closed400"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) tt. ft. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ir.
Industriaucommercial E3Residential Water Supply(shared) i
.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Bentonita
Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK-(if a`7icable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain sin,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
0 it. 43 ft. Clay
4.Date Well(s)Completed: 06/18/21 Well ID# 43 ft. 505 ft, Granite
5a.Well Location:
Noah Mencia
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1920 Rabbit Skin Rd. Waynesville 28785
Physical Address,City,and Zip ft. ft.
Haywood 8710-21-7597 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) 2 erti cation: I
35.616 N 82.989
06/18/21
6.Is(are)the well(s)oPermanent or Temporary Signatfire of Certifie Well Contrac or 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 ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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.
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drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (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 tliis,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) 2 Method of test: 2 Hours 24c.For Water Supply&Iniecton 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: 92 Tabs completion of well construction to the county health department of the county
where constructed. k
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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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