GW1-2022-10171_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: t
1.Well Contractor Information: k
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Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIP4TION
2418 p ft. 205 ft. 30ycm
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER':if a licab e
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 60 ft. 1 61/4 i, in. Steel
Company Name
MCM-1 O 1 W 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
,1
Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. Bentonite
Monitoring Recovery
In
Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soil/rock e, in size,etc.
)ft.ft. 60 ft. Clay
4.Date Well(s)Completed:09/14/22 Well ID# 60 ft 225 ft' Granite
5a.Well Location: PFUN=11 lam
Cody Corn ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft NOV O
3077 Plott Creek Rd. Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft. Q"USxs
Haywood 8695-64-6142 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. lion•
35.480 N -83.043 W
09/14/22
6.Is(are)the well(s)0 Permanent or Temporary Signature VC rtified 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
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 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: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
+Artesian
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,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: G
(i.e.auger,rotary,cable,direct push,etc.) f
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.For Water Supply&Iniectil n 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: 4o tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I Nord)Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016