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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 f