GW1-2023-00436_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 80 ft. 39om 1
2418
80 ft• 205 ft. s9Pm
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
0 ft. 57 ft. 1 6114 - in. PVC
Company Name
W E L2�21-��124 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,Count)',State,Variance,etc.) ft. tL in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
HAgricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT r s,
' Irripation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring QRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
-. Experimental Technology DSubsidence Control
I Geothermal(Closed loop) ]❑]Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilfrock t e. rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
p ft. 57 ft. Clay i
4.Date Well(s)Completed: 11/18/22 Well ID# 57 ft. 305 ft.
Granite
5a.Well Location:
William Stacy Moore
Facility/Owner Name Facility ID#(if applicable) ft. ft. 14
,
23 Mountain Tea Ln.Alexander 28701
Physical Address,City,and Zip ft. ft. EO;v;; _u S pi n-'W�Rm"3 Una'
Buncombe 9723-70-68620000 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. ertifiea'on'
35.704 N -82.611 W
11/18/22
6.Is(are)the well(s)oPermanent or OTemporary Signature of 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: Dyes or X)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 I 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: 305 (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: i
I
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'n (in.) 24b.For Injection Wells: hi 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) 6 Method of test: 2 Hours 24c.For Water Suably&Iniectiou 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: ss 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