HomeMy WebLinkAboutGW1-2022-08218_Well Construction - GW1_20220411 Print Form.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb _ r, 1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
p ft- 205 ft svm
2418 APR 11 202? 205 ft* 305 ft. 9�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
Greene Bros Well & Pump WT Inc ` (,>l FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. - in.
Company Name py ,c'*;', ",Tr{ "I rl ,.r,", iUT•' 0 85 61/4 Steel
J M Q- 10W 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.
Y7.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural ®Municipal/Public tt. ft. in•,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
_ lndustrial/Commercial Residential Water Supply(shared)
18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft• Bentonite
Monitoring DRecovery
Injection Well:
rt. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soitfrock type,grain size,etc.
p ft. 85 IL Clay
4.Date Well(s)Completed: 3-29-2022 Well ID# as ft 305 ft Granite
5a.Well Location:
Tyler Howell
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2480.Coleman Mountain Rd. Waynesville, NC 28785
Physical Address,City,and Zip ft. ft.
Haywood 8618-89-0276 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. ertific lion•
35.423 N 82.925 /
03-29-2022
6.Is(are)the well(s)OPermanent or 13Temporary Signature of Certified Well Contractor E 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 knc,'c,i Nell consins6ion 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: 305 (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:
I
10.Static water level below top of casing: 5 (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 On-) 24b.For Iniection 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) 8 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: 107 tabs. completion of well construction to the county health department of the county
where constructed.
E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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