GW1-2021-02621_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 205 ft oosvm
2418
tt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if_a licable
Greene Brothers Well 8t Pump, WT Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 84 rL 6114 1 in. SDR21
Company Name
WEL2021-00234 16.INNER CASING OR TUBING eothermalclosea-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public
Geothermal 1(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. tt. t"'1
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite
Monitoring Recovery
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 13Stormwater Drainage
Experimental Technology Subsidence Control
i
Geothermal(Closed hoop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft. ea ft• Cla
Y
4.Date Well(s)Completed:07/14/21 Well ID# 84 ft. 225 ft,
Granite;
5a.Well Location:
Louie Justus tt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
25 Wise Rd. Candler 28715 V b
Physical Address,City,and Zip ft. ft. por eSsims
Buncombe 9605-38-3662 21.REMARKS 1PAG3 11
0
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 2 . erti£ ation:
35.505 N 82.685 W
07/14/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor ! Date
By signing this form,I hereby certify that the we/l(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 01C.0200 Well Construction Standards and that a
Ifthis 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: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
Ifwater 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) 100 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: ao Tabs completion of well construction to the county health department of the county
where constructed.
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016