GW1-2022-10812_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
p ,
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 It. 1 220 ft. zyam
220 ft. 420 ft. evm
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 MATERUL
Company Name 0 ft. 47 ft. 1 6 114 1 in, I PVC
J M Q-234W 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.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. irI•
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. ih.
Industrial/Commercial OResidential Water Supply(shared) f
18.GROUT
_11niization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring Recovery
[Experimental
n Well:
ft. ft.
er Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if a licable)
er Storage and Recovery ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test [3Stormwater Drainage Technology Subsidence Control ft. fr.
ermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION(color,hardness,soiltrock t e, rain size,etc.ermal(Heating/Cooling Return) ;—' Other(explain under#21 Remarks)
0 ft. 47 ft. Clay
4.Date Well(s)Completed: 10/03/22 Well ID# 47 ft. 505 ft, Granite
5a.Well Location:
Hattie Christine Jaynes Waddell
Facility/Owner Name Facility ID#(if applicable)
ifrivC�(i�S+"" •�
164 Ragwood Ln.Waynesville 28785
Physical Address,City,and Zip
Haywood 8627-55-5303 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) 2.
35.541 -82.948
i r
N w —` 10/03/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified 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: QYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 01C.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 lire 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:_1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100) construction to the following: i
10.Static water level below top of casing: 60 (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 Iniection Wells: In addition to sending the form to the address in 24a
form within 30 days of completion of well
Rotary above, also submit one copy of this
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(,-pm) 3 Method of test: 2 Hours 24c.For Water SuDDIv&Iniec�tiln Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: s2 tabs completion of well construction Itolthe 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