GW1-2022-09502_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES _
Well Contractor Name FROM TO DESCRIPTION 2418 -
p ft. 85 fl. 30gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells 0 .LINER,if a licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p ft. 43 ft. 61/4 { in. Steel
Company Name A G
2022-22784-9-11857 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L O O 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.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothenmal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. i4.
I__ Industrial/Comrtercial DResidential Water Supply(shared) .18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. l3entonite
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
(— Aquifer Storage and Recovery E]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
L_ Aquifer Test 0Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
i— FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) p ft 43 rt Clay
09/01/22 ft. ft. j
4.Date Wells)Completed: Well ID# 43 105 Granite.''
Sa.Well Location: ft. ft..
�'
ft. .ff.. �• 5 `<,?.z,.Uzi..,+'�.:< fl d��....,e.�.1
Margie Bishop T
Facility/Owner Name, Facility lD#(if applicable) ft. ft. ( 0 C I 1
41 Civic Ln. Cullowhee 28723Oft
ft ft:
Physical Address,City,and Zip ft. ft." r VI,,r Eli_,
Jackson 7660-01-3253 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. ertif ation:
35.331 N -83:155 W 09/01/22
6.Is(are)the well(s)Jz Permanent or OTemporary Signatu e o Certified Well Contractor i 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: nYes or ONo 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 ivell 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: 105 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100�. t
construction to the following: �
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casii g,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
6. 1/4 _ i
11.Borehole diameter: (in.) 24b.For Injection 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) 30 Method of test: 2 Hours '24c.ForWater SuDDIy&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: 18 tabs completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources, Revised 2-22-2016