GW1-2022-03874_Well Construction - GW1_20220406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4238 o u. 160 it. ,�9om e
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mold-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DL4METER THICKNESS MATERIAL
0 ft. 65 ft. 61/4 ' in- I SDR21
Company Name
M_298W 16.INNER CASING ORTUBING eothermalclosed-loo MC
2.Well Construction Permit#: 'VI 98 V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic [t. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ia•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. eentonite
Monitoring Recovery ft. R.
Injection Well:
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test rIStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®ITracer 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. 65 ft, Clay
4.Date Well(s)Completed:03/09/22 Well ID# 65 ft• 185 ft• Granite
ft. ft.
5a.Well Location:
Fred Clark ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft _ �
344 Pisgah Creek Rd. Canton 28716 ft. ft. 7
Physical Address,City,and Zip
Haywood 8663-91-7388 21.REMARKS
County Parcel Identification No.(PIN) !,,rromwai, h"0IESJFvG Lh\q7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
35.426 N -82.792
�/ 03/09/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified 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
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: 185 (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@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 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) 100 Method of test: 2 Hours 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: ss cats 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