GW1-2022-10814_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
2418 p % 165 ft. zsgvm 1
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
p ft. 89 ft. 61/4 I, in. Steel
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: SAS-224W 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): n•
Water Supply Well: i SCREEN FRR SCTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. io•
_- Industrial/Commercial []Residential Water Supply(shared) is.GROUT '
i hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
Monitoring ORccovery
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 I[]Stormwater Drainage
Experimental Technology n Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) p ft. 89 ft. Clay
4.Date Well(s)Completed: 10/12/22 Well ID# S9 ft. 185 ft' Granite
5a.Well Location:
Trevor Roberts
Facility/Owner Name Facility ID#(ifapplicable)
L LL
65 Dana Farm Rd. Maggie Valley 28751 ft. ft. rr..;, .�>;;r�t rs
Physical Address,City,and Zip ft.
Haywood 7687-40-0511 21.REMARKS
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 ertifiea' n:
35.524 N -83.087 W f
L 10/12/22
6.Is(are)the well(s)OPermanent or 1[]Temporary Signature of Certified Well Contractor' Date
By signing this fonn,I hereby certif},that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EJNo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis 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: 185 (ft.) 24a. For All Wells: Submit th I is form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing:40 (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) 25 Method of test: 2 Hours 24c.For Water Suppiv&Inieclti In 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: 33 tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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