GW1-2022-03115_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 285 ft. 20awn
2418
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well 8t Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 64 ft. 61/4 ' in.
Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2019-13300-9-11103 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in•
4
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. ft. idI
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK',tf il filicatile
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfrock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 64 ft. Clay
4.Date Well(s)Completed:01/13/22 Well ID# 64 ft 305 ft, Granite.
Sa.Well Location: ft. ft.
Sharon Harshaw/Balsam Builders ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
152 Big Gobbler Branch Syvla 28779 ft. ft.
Physical Address,City,and Zip ft. ft.
Jackson 7683-72-0819 21.REMARKS
County Parcel Identification No.(PIN) C}, m'vic
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AN KN ER Or, " Ili
(if well field,one lat/long is sufficient) 22. rtifre 'on:
35.421 N -83.073 W
01/13/22
6.Is(are)the well(s)OPermanent or Temporary Signature of ertified Well Contractor 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: ®Yes or ®NO 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 421 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.
dried: 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 f different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 80 (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: 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
13a.Yield(gpm) 20 Method of test: 2 Hours 24c.For Water Supply&Injection 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: 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