GW1-2022-03114_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
p ft. 185 ft. iovwn
2418 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS iATERIAL
p tt. 35 ft. 61/4 in• SDR21
Company Name
2021-21301-9-11334 16..INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(r.e.VIC,Couno%State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public
i
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 20 tt Benlonite
Monitoring DRecovery
Injection Well:
ft. tt.
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test F_ Stormwater Drainage fl ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soilfrock G in size,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) 0 g 35 ft, Clay
4.Date Well(s)Completed: 01/27/22 Well ID# 35 ft 305 tt Granite
5a.Well Location:
ft. ft.
Michael &Wendy Trull
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. '
97 Thunderbird Rd. Sylva 28779
Physical Address,City,and Zip ft. ft. �
Jackson 766145-7089 21.REMARKS r;,p_,�•.•....
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Ce 'Icah n:
35.367 N -83.139 W
01/2 7/22
6.Is(are)the well(s)oPermanent or E37femporary rgnature o rtificd Well Con ctor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or E]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-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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@I00) 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: 6 1/4 (in.) 24b.For Iniection 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
13a.Yield(gpm) 10 Method of test: 2 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: 56 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