GW1-2022-09292_Well Construction - GW1_20221006

WELL CONSTRUCTION RECO E1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene SEP 2 2022 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name NC DEQ/DWR 0 ft. 125 ft. I.W.
4238 Central Office 125 ft- 1 245 ft' 41;, 1245 WW3ogpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells SS OR LINER if a ticable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNEMATERIAL
0 ft. 84 It. 1 61/4 in. Steel
Company Name
SAS-178W 16.INNER CASING OR TUBING(geothermal closed-too
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): tt. ft. in.
[ln ,a
Supply Well: 17.SCREEN -'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ultural ®MunicipaUPublic R. ft, in.
hermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. tt. in,
trial/Commercial [3Residential Water Supply(shared) 18.GROUT
tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 ft. PO ft. gentonite
itoring r1lRecovery
on Well:
ifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if"a" licable i
fer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fer Test �Stormwater Drainagerimental Technology Subsidence Controlhermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color hardness,soil/rock e, rain size,etc.hermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 82 ft. Clay
4.Date Well(s)Completed: 08/05/22 Well ID# 62 ft• 305 ft• Granite
5a.Well Location:
Kim &Joanne Wilson ft. ft. '" .r, z-•-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. OCT U 6 202Z
1933 Black Camp Gap Rd. Maggie Valley 28751
Physical Address,City,and Zip ft. ft. I`" '�:�';}r"l�`-:
Haywood 7666-49-6480 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
35.518 N -83.152
08/05/22
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor; 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
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#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-I 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:
10.Static water level below top of casing: 40 (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 A (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
(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) 9 Method of test: 2 Hours 24c.For Water Supply&Injection 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: 56 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