GW1-2022-03112_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name p ft• 305 ft• zsnm
#2418
485 ft 505 ft. ,wpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Bros. Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 P9 ft. 61/4 to Steel
Company Name
SAS-205 W 16.INNER CASING OR TUBING(geothermal closed-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): ft. it. in.
IN
ter Supply Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural ®Municipal/Public ft. ft. id
6
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. iF
dustrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring Recovery
ection WeII:quifer Recharge ®Groundwater Remediation
19...SAND/GRAVELPACK if a" lkitblequifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test E]Stormwater Drainagexperimental Technology SubsidenceControleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color,hardness soil/rock e, rain size,etc.eothermal (Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 29 ft, Clay
4.Date Wells Completed:02/16/22 Weil ID# 2s ft• 505 ft.
() p Granite'
ft. ft.
5a.Well Location:
Jeremy Bolden
Facility/Owner Name Facility ID#(if applicable) ft. ft. y..,., F
Balsam Ridge Rd Waynesville, NC 28786
Physical Address,City,and Zip ft. ft. —
Haywood 7684-97-4020 21.REMARKS
i Ir
County Parcel Identification No.(PIN) � Fes, UNI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22. erotica 'on: 1
35.476 N 83.069 W
02/16/22
6.Is(are)the well(s)oPermanent or Temporary Signature ofCcrtified 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 ®No 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled'I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit thii form within 30 days of completion of well
For multiple wells list all depths if ell ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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 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,JUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 20 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: s2 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