GW1-2023-00455_Well Construction - GW1_20230109

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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 165 ft. zoq-
2418 f
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER H a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p ft. 53 ft. 6114 • in' PVC
Company Name
M C M-370W 16.INNER CASING OR TUBING eother al 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 DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
I idustrial/Commercial IDResidential Water Supply(shared) 18.GROUT
.1-thTilzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. Bentanite
f Monitoring Recovery
i(Geothermal
jection Well:Aquifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainagexperimental Technology Subsidence ControlGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessaFROM TO DESCRIPTION(color,hardness,soillrock lv e, rain size,etc.)
(Heating/Cooling Return) I Other(explain under#21 Remarks) 0 ft. 53 ft' Clay
4.Date Well(s)Completed: 12/15/22 Well ID# 53 ft' 185 ft' Granite
5a.Well Location:
Katherine Kulakova ft. ft. - =�
i
Facility/Owner Name Facility ID#(if applicable) ft, ft. U ..
390 Vision Rd. Canton 28716
Physical Address,City,and Zip ft. ft. %Jt
Haywood 8668-32-2349 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) 22.oCediftaon•
35.565 N -82.823 W
� �. `� 12/15/22
6.Is(are)the well(s)X Permanent or IOTemporary Signature OCertified 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: lYes or nNo 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 farm:.
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. Yoii may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (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@100D construction to the following:
10.Static water level below to 20
p of casin g: (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 27699-1636
13a.Yield I
(gpm) 20 Method of test: 2 Hours 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
the address(es) above, also subinii one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 33 tabs completion of well construction(tol 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