GW1-2022-05806_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information: j
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Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 p ft. 445 ft. seam
445 ft. 605 ft. esgam
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 80 ft 61/4 iin. SDR21
Company Name
GJB-167W 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n. 20 ft. Bentonite
Monitoring ®Recovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft- 80 ft. Clay
4.Date Well(s)Completed: 04/26/22 Well ID# 80 ft. 625 ft.
Granite ...e
5a.Well Location: ft. ft. 1 L)
Mark Rogers
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
84 Asbury Rogers Rd. Clyde 28721 ft. ft. ln3ot ft o�PmCW—'1g Unh
Physical Address,City,and Zip ft. ft.
Haywood 8649-04-6447 21.REMARKS"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tifiCa on:
35.596 N -82.900 W
04/26/22
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)constricted in accordance
7.Is this a repair to an existing well• ®Yes or O1 No with 15A NCAC 02C.0100 or I5A 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: 625 (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 (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
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13a.Yield(gpm) 10 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: 113 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016