GW1-2022-10237_Well Construction - GW1_20221111

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
2418 o rt. ass It
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ii able
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 IL 100 ft- 61/4 in. PVC
Company Name
2022-23185-9-12061 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.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER;: SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.l
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.I
Industrial/Commercial 13Residential Water Supply(shared)
18.GROUT
Irfi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 tt. Bentonite
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrock e, rain size etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
p ft. 100 it• Clay
ft. ft.
4.Date Well 10/04/22 s)Completed: Well ID# 100 385 Granite.
ft. ft.
5a.Well Location:
Steve Meadows rt. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV
1512 Cold Springs Dr. Maggie Valley 28751UR—
Physical Address,City,and Zip tt. ft. rtaorpna.I5r,� fC r''.ylT>"
Jackson 7655-76-8052 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.C lion:
35.482 N -83.172 W
10/04/22
6.Is(are)the well(s)OPermanent or 1 Temporary Signature f3f Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes 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: 385 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifJerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 130 (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 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,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 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: 71 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