GW1-2022-10189_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 11- 340 ft. 3D9Pm
4238 it. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER LINER if a licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETERF THICKNESS MATERIAL
p ft. 80 ft. 1 61/4 in. PVC
Company Name MC M-265W 16.INNER CASING OR TUBING(geothermal closed-loo
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.
IT SCREEN
i"Irrigation
ater Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. in!
Industrial/Commercial [3Residential Water Supply(shared)
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 6entonite
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/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) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) l
FROM TO DESCRH'TION color,hardness,soil/rock type, rain size,etc.)
0 ft. 80 ft. Clay
4.Date Well(s)Completed: 09/28/22 Well ID# 80 ft. 365 it Granite
5a.Well Location: ft. ft.
Cody Corn rt. it.
NOV 2022
Facility/Owner Name Facility ID#(if applicable) ft. ft.
243 Harmony Ln. Waynesville 28785Irt�olriirwtttiilefl Prrc! oing Unil
Physical Address,City,and Zip ft. ft.
Haywood 8629-03-4721 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:
35.591 N 82.968 W
n� 09/28/22
d.4
6.Is(are)the well(s)OPermanent or Temporary giature of Certified We 1 Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 01C.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: 365 (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 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: 61A (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.)
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) 30 Method of test: 2 Hours 24c.For Water Supply&Infection 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: s�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 Resourcesr. Revised 2-22-2016