GW1-2022-09504_Well Construction - GW1_20221014

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.wATERzoNEs
Well Contractor Name FROM TO DESCRIPTION
0 ft 80 ft. 209pmred#er
2418
80 ft. 190 ft. sosam
NC Well Contractor Certification Number -15.OUTER CASING for multi cased iIvells OR LINER if a lieable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 30 ft. 6114 � ( in' I PVC
Company Name
-��1 W 16.INNER CASING OR TUBING(geothermal closed400
S
2.Well Construction Permit#: AS FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIG County,State,Variance,etc.) ft. ft. t in.
1 ,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. id•
I Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
I Monitoring DRecovery
8Aquife,
jection Well:
Recharge Q Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)_
Aquifer Storage and Recovery f©I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
(—Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sod/rock type,gmin size,etc.)
0 ft. 30 It. Clay
4.Date Well(s)Completed: 09/06/22 Well ID# 30 ft. 205 ft• Granite
5a.Well Location:
Ron Cameron
.Facility/Owner Name Facility ID#(if applicable)
110 Big Bear Rd. Waynesville 28786 ft. fr. 0C 1 14
Physical Address,City,and Zip ft. ft. ?C•r� } : Unil
Haywood 8614-70-4963 -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) .Certi cation: I
35.446 N -82.971 W I 09/06/22
6.Is(are)the well(s) iX Permanent or [3Temporary Signature of Certified well Con r ! 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: E]Yes or EX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction 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 421 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (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@100 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing.Unit,
Ifwater level is above casing,use"+" 1617 Mail Service jenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4' (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.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) 50 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: as 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