GW1-2021-02109_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD ( =T) - For Internal Use Only: I
I.Well Contractor Information:
i
Travis Greene 1=1 r Jr,11 r) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 4238 0 ft. 125
J U L 0 9 2021 ft. ft.
NC Well Contractor Certification Number .OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well &Pump, WT 199formatlon processing OM TO DIAMETER THICKNESS MATERIAL
Company Name RIVAV SAGA 0 ft• 105 ft' 6 1/4 to Steel
SAS-122W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well constntction permits(i.e.UIC.County.State. Variance•etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER; SLOTSIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public tt. tt. in•'
Gcothennal(Heating/Cooling Supply) Residential Water Supply(tingle) ft. tt. in'
Industrial/Commercial [3Rcsidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AaIOUNT
Non-Water Supply Well: 0 tt. 20 ft• eentonite
Monitoring ORccovcry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT MF,THOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type, rain sire,etc.
Geothermal(Heating/Cooling Return) ' Other(explain under#21 Remarks)
0 ft. 105 ft, Clay
4.Date Well(s)Completed: 06/02/21 Well ID# 105 ft. 185 ft. Granite
Sa.Well Location:
ft. ft.
Taylor&Janice Hughes ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
496 Stepping Stone Ln Waynesville 28786 ft. ft.
Physical Address,City,and Zip
ft. ft.
Haywood 8624-19-9800 21.REMARKS
County Parcel Identification No.(PIN)
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.471 82.958
N w 06/02/21
6.Is(are)the well(s)OPermanent or ©ITemporary Signature of Certified W 11 Contractor 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 XJNo 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 conrtniction 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 I 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: 185 (ft-) 24a. For All Wells: Submit thils form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing:40 (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.) 241b.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) 10 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: 33 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