GW1-2022-10816_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb 14.WATER ZONES ;
FROM TO DESCRIPTION
Well Contractor Name
2418 o ft. 185 ft' 29Pnt `
185 n, 465 ft. 9Pn f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased i ells OR LINER if
livable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 27 ft. 6 1/4 1 :in. PVC
Company Name
MCM-316W 16.INNER CASING ORTUBING(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.
Water Supply Well: FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. In•
Industrial/Commercial IDResidential Water Supply(shared) t
18.GROUT'
i_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft Bentonite
f Monitoring DRecovery
[Experimental
n Well:
ft. ft.
er Recharge '� Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test OStormwater Drainage
Technology Subsidence Controlermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessa )
FROM TO DESCRIPTION(color,hardness,soil/rock t e, rain size,etc.)
ermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) 0 ft. 27 ft clay
11/08/22 27 ft. 505 . Granite
4.Date Well(s)Completed: Well ID# ft
5a.Well Location:
Erica Hamilton
Facility/Owner Name Facility ID#(if applicable) ft. ft.
609 Worley Cove Rd. Canton 28716 ft. ft. >v i ;U a U_5 V RZ LJ
Physical Address,City,and Zip ft. ft. 7
Haywood 8669-30-4632 21.REMARKS =-
;� r�^Pinc1 Ur.';'
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22. is 'on: j
35.587 N -82.822 W
l) 11/08/22
6.Is(are)the well(s)oPermanent or E3Temporary Signature of Certified Well 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: nYes or X)No with ISA NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a
If tins 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: 505 (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: 100 (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 Injection 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.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 2 Hours 24c.For Water Suppiv&Injection 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: 92 Tabs completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016