GW1-2023-00451_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4238 o ft. 305 ft' ievm
305 ft. 600 ft. Sgp.
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. 83 ft. 61/4 in
PVC
Company Name SAS-250W 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. I, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C]Municipal/Public ft. ft. i •
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single)
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. Bentonite
i Monitoring iDRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable).
i— Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
i Geothermal(Closed Loop) IDTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e,grain size,etc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) 0 ft. 83 ft, Clay
4.Date Well(s)Completed: 12/02/22 ft.. Well ID# 63 705 ft, Granite
Sa.Well Location: ,• tk�-i'' e, '•.�; r n
Andrew Bryan i
Facility/Owner Name Facility 1D#(if applicable) ft. tt. J A N 0 9 ZOD
94 Leopard Dr. Waynesville 28786 f` f` Pr.��-�;
Physical Address,City,and Zip ft. ft. e
Haywood 8625-26-1619 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.Certification:
35.490 N -82.957 W
12/02/22
6.Is(are)the well(s)EIPermanent or Temporary Signature of Certified Well Contractor I ! 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: OYes or rXJNo 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: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following: j
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
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 276994636
13a.Yield(gpm) 1.5 Method of test: 2 Hours 24c.For Water SuDDIy&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: 127 Tabs completion of well construction to Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource i Revised 2-22-2016