GW1-2022-10186_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft- 585 ft. 609M
2418
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 67 It. 1 61/4 4 in. PVC
Company Name
SAS-235W 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.a UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
SCREEN17.
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. inJ
Geothermal(Heating/Cooling Supply) Oj Residential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 6entonite
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remedial ion
191SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrock type, rain size,etc.
0 ft. 87 ft. Clay
4.Date Well(s)Completed: 10/14/22 Well ID# 67 ft. 605 ft Granite f
ft.
5a.Well Location: ft. Mr— M% V!M1t DIP
Leila Wheless
Facility/Owner Name Facility ID#(ifappfrcable) ft. ft.
Lothloran Dr. Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft. lr40"na z)n Pr.-...- U►ul
Haywood 8635-29-9572 21.REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.499 N -82.917 W
10/14/22
6.Is(are)the well(s)oPermanent or Temporary Signatur of Certified Well Contractor Date
By signing this form,I hereby certijj,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 tinder#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: 605 (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: 400 (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 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:
(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) 60 Method of test: 2 Hours 24c.For Water Supply&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: 109 Tabs completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016