GW1-2022-03113_Well Construction - GW1_20220303

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 0 fL 305 ft- 3GPM
1305 fa 485 ft. 3GPM j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
Greene Bros Well & Pump, WT Inc FROM To DIAMETER TatCKNEss MATERIAL
Company Name p 0 ft. 91 ft. 61/4 in SDR-21 PVC
J M Q-208 V V 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER I 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. in.
17.SCREEN '
Water Supply Well: FROM TO DIAMETER ! SLOTSIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [ Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• Bentonite
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL.PAC K if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Traeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soil/mck tyM grain size etc.
0 ft. 91 ft. Clay
4.Date Well(s)Completed:02/22/22 Well ID# 91 fL 505 1 Granite
5a.Well Location: ft ft.
Holly Sutherlin/Blake Ellege ft ft. '
Facility/Owner Name Facility ID#(if applicable) ft ft. MAR 0
5934 Liner Creek Rd Clyde, NC 28721 ft. ft. _
tjl .?3�t i tai
Physical Address,City,and Zip ft ft.
Haywood 8750-07-7399 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweI1 field,one lat/long is sufficient) 2 .Certif ation•
35.604 N 82.905 W 02/22/22
6.Is(are)the well(s)13Permanent or 13Temporary Signature of Certified Well ontractor 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 E3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (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 1@100') construction to the following:
10.Static water level below top of casing: 140 (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 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction methodRotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)6 Method of test-2 HOuIs 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: 92 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