GW1-2022-07390_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 tt. 85
4238
NC Well Contractor Certification Number 15.OUTER CASING for mu1H-eased wells OR LINER ifa licable
Greene Brothers Well & Pump, WT Inc. oM TO DIAMETERI THICKNESS MATERIAL
0 ft 54 tt 61/4 1 in. Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loopl
GJB-177W FROM r�� DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft j in.
List all applicable well construction permits(i.e. UIC,County,State.Variance,etc.)
tt. ft. in•
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ii•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. gentonite
Monitoring DRecovery tt. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK Ctfa licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT hIETHOD
Aquifer Test [3 Stormwater Drainage ft. k.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiUrock- e, in size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft- 54 ft Clay
07/01/22 54 ft. 125 tt Granite
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Michael Loukinen rt. rt. -10 ;"'V _ I
b'ID#Facility ifapplicable)
ft, ft.
Facility/Owner Name C
13428 Cruso Rd. Canton 28716
ft. ft. 1�f:•;;W V' '.EJ ni.
Physical Address,City,and Zip ''` �```�
Haywood 8662-48-1285 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.Certification:
35.416 N -82.812 W 07/01/22
C�.(1ze.Lc.aJ ���_✓
Signature of Certified Well Contractor Date
6.Is(are)the well(s)OPermanent or 13Temporary
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 EJNo 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 ofthe copy ofthis record has been provided to the well owner.
repair under#11 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: 125 (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@1001 construction to the following:
10.Static water level below top of casing: 20 (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 276994636
13a.Yield(gpm) 30 Method of test: 2 Hours 24c.For Water Sunniv&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: 22 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