GW1-2022-03870_Well Construction - GW1_20220406

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 ft. 165 ft. Bosom
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 61/4 in. SDR21
Company Name LI
—24 pO W 16.INNER CASING OR TUBING(geothermal closed-loop)
N r1 -
2.Well Construction Permit#: R 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. ft. in.
17.
Water Supply Well: FROSMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in4
Industrial/Commercial Residential Water Supply(shared) 18-GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring DRecovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology 0Subsidence Control
i
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) 0 ft. 70 ft. Clay
4.Date Well(s)Completed: 03/16/22 Well ID# 70 ft 285 ft Granite,
ft. ft.
5a.Well Location:
Stephen Link
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. E .
Forbidden Cove Waynesville 28785
Physical Address,City,and Zip ft. ft.
Haywood 7699-16-3168 21.REMARKS IRA 0
County Parcel Identification No.(PIN) - Pop M,
'
q .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 erti cation:
35.594 N -83.066 WL74;�Vo ` 03/16/22
6.Is(are)the well(s)oPermanent or ®]Temporary Signature of Certified 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.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 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: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 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 Injection 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 pusb,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&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: 61 Tabs completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016