GW1-2022-09503_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
Robin Webb 14.:WATER ZONES
.
Well Contractor Name FROM TO DESCRIPTION
0 ft. 185 ft* 129Pm
2418
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a Gcable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. 61/4 I in. Steel
Company Name
SAS-220W 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single)
I_ Industrial/Commercial [3Residentlal Water Supply(shared) ls.GROUT-..
_ hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 it. Bentonite
I— Monitoring Recovery ft. ft.
[Geothermal
n Well:
ft. ft.
er Recharge Groundwater Remediation
19..SAND/GRAVEL PACK if applicable)
er Storage and Recovery I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test OStormwater Drainage
mental Technology Subsidence Control(Closed Loop) Tracer 20.DRILLING LOG. attach additional sheets if necessaFROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
ermal(Heating/Cooling Return) i Other(explain under#21 Remarks)
Q ft. gp ft. Clay 1 '
4.Date Well(s)Completed:09/07/22 Well ID# 90 ft. 245 ft. i
Granite
Sa.Well Location: 'i�� �•' ,
Gary Wyatt rt. rr.
Facility/Owner Name Facility ID#(if applicable)
65 Waverly Dr. Waynesville 28786
Physical Address,City,and Zip
Haywood 8603-37-2823 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. ertifica on: { ;
35.435 N -83.108 W -
09/07/22
6.Is(are)the well(s)JOPermanent or OTemporary 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 exjsdiig well• E]Yes or X 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#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 alsolattach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 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: 60 (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 (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: 4
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: 2 hours 24c.For Water SuDnly&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: 4s 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
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