GW1-2022-07389_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2418 0 ft. 505 ft. �anm
505 ft* 525 ft. aoeam
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells)OR LINER if a Qcable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 66 ft. 61/4 " in. SDR21
Company Name
MCM'3OZW 16.INNER CASING OR TUBING(geothermal 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
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ii• '
Industrial/Commercial ORcsidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 R. Bentonite
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19:'SAND/GRAVEL PACK'if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain sim,etc.
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks
0 ft. 66 ft, Clay
4.Date Well(s)Completed:06/29/22 Well ID# 66 ft 545 ft Granite
5a.Well Location:
Matthew Ledford
Facility/Owner Name Facility ID#(if applicable) ft. ZZ
57 Briar Ln. Clyde 28721 ft. ft.
Iflti:� C-1 I ..i,..-
Fn`sd�
Physical Address,City,and Zip ft. ft. `^ 0G
Haywood 8627-92-9849 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 eetifi ation.
35.535 N -82.934 W
06/29/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified e 1 ontractor! 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 01C.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: 545 (ft) 24a. For All Wells: Submit tliis 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: 100 (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.) i
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'hCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 61 Method of test: 2 Hours 24c.For Water Supply&Iniecition 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: 2 Hours Amount: 99 tabs completion of well construction Ito the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016