GW1-2022-03054_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 285 ft. ,opm
4238
285 ft, 525 ft. u¢pm
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ti�ells O LIN R ER If a cabl lie
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS ARTERIAL
0 Company Name ft. 77 ft. 6114 in. Steel
MCM-306W 16.INNER CASING OR Tv131NG(geothermal dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well: .
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural []Municipal/Public tt. tt. in.
_'Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. in.
Industrial/Commercial ORcsidential Water Supply(shared)
18.GROUT i a:
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. Bentonite
Monitoring Recovery ft. ft.
Injection WelI.
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licabie
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. I ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness$0/rock type, rain sir etc.
Geothermal(Heating/Cooling Cooling Return) ; Other(explain under#21 Remarks) 0 ft. 77 ft. Clay �
4.Date Well(s)Completed:02/09/22 Well ID# 77 ft. 705 ft* Granite
ft. ft.
5a.Well Location:
Farmworks LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft.
245 River Farm Ln Canton 28716 $. ft. i"�a, v • '
Physical Address,City,and Zip ft. ft. MAR
Haywood 8644-17-1382 21.REMARKS `E
County Parcel Identification No.(PIN) t v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AIM
( `
(if well field,one lat/long is sufficient) 22.Certification:
34.416 N -82.928 W �
6.Is(are)the well(s)OPermanent or Temporary Signfiture of Certified Well Contractor Date
By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or FJNo with 15A NCAC 02C.0100 or I5A NCAC 01C.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 tinder#21 remarks section at-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 i
9.Total well depth below land surface: 705 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f diifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 10 (ft.) 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 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
13a.Yield(gpm) 11 Method of test: 2 Hours 24c.For Water Supply& Iniectio i Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 127 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016