GW1-2022-09285_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Tobin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 SEp 2$ 2022 ft 285 rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc- NC DEQ/GwR FROM TO DIAIYfETER THICKNESS MATERIAL
ifice 0 ft- 26 ft. 1 61/4 in. PVC
Company Name
2021-20989-9-11035 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.VIC,County.State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural OMunicipal/Public ft. ft. in,
_. Geothermal(Heating/Cooling Supply) OResidcntial Water Supply(single) (t. ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 1S.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt• Bentonite
Monitoring EIRecovery
Injection Well:
_ Aquifer Recharge ®i Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
Geothermal Heating/Cooling Return) Other explain under#21 Remarks) 0 ft. 26 rc• Cl
ay
4.Date Wells Completed:08/15/22 Well ID# 26 ft. 305 ft.
() P Granite
Sa.Well Location: ft. ft. -
David McAlpin rt. ft. h` 4b..;S_..- 'e
.,
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft.
1856 East Reach Rd. Sylva 28779 ft. ft.
Physical Address,City,and Zip ft. ft. •
Jackson 7672-84-7706 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latllong is sufficient) 22.Cer• ti0ri:
35.397 N -83.099 W .
08/15/22
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor! Date
By signing this form,I hereby certify that the urll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: bYes or E)No with 15A NCAC 02C.0100 or 15A 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 a•on the back of this farm.
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(evarnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+•• 1617 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 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 ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 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: ss 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