GW1-2022-03052_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 785 ft. 7za�
2418
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 f1- 47 ft. 61/4 in' Steel
JCH-008W '16.INNERCASINGORTusING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,Count),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
17.
ihiiRation
ater Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in'.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. mi
dustrial/Commercial [3Residential Water Supply(shared) 18.GROUT t
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt 20 rt Bentonite
Monitoring pRecovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test J3Stormwater Drainage
ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock rain sin,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks 0 ft. 47 ft, Clay
4.Date Wells Completed:02/18/22 Well ID# 47 ft. 205 ft.
() p Granite
5a.Well Location: r
James & Loren Watts rt. ft. MAR 0 3 mg
Facility/Owner Name Facility ID#(if applicable) ft. ft.
656 Winding Creek Dr. Waynesville 28786 it. ft. .icy,,WE C IRA
Physical Address,City,and Zip
ft. ft.
Haywood 7695-07-9604 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Ce ' ea'on•
35.487 N -83.069
02/18/22
6.Is(are)the well(s)OPermanent or Temporary Signature o Certified well 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: ®Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:60 (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: 61 A (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
4
13a.Yield(gpm) 12 Method of test: 2 Hours 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subniIit'one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ss 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