GW1-2023-00474_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
p Ct• 480 It.4238 238om
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 DIA11H R THICKNESS MATERIAL
p ft. 72 ft. 61/4 1°. PVC
Company Name
2022-23075-9-12101 16.INNER CASING OR TUBING- eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS IMATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in,
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public Ct. ft. ip•
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) it. ft. in.
Industrial/Commercial DResidential Water Supply(shared) .18.GROUT
I hri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 Ct. 20 tt. Bentoniie
I Monitoring QRecovery
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
! Aquifer Storage and Recovery l_J Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©!Stormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) rl Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soilfrock type,"rain sue,etc.
p ft. 72 ft- Clay ,
4.Date Well(s)Completed: 12/13/22 Well ID# 72 ft. 565 M
Granite
ft. ft.
5a.Well Location:
Brian Battin
Facility/Owner Name Facility ID#(if applicable) ft. ft. ly
3921 Preserve Rd. Sylva 28779 ft. ft.
Physical Address,City,and Zip ft. ft ..,�;� t;�i ^; kin;l
Jackson 7671-69-0670 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.Certitication-
35.380 N -83.111 W
12/13/22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified We�rContractorj ! Date
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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 XINo 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: 565 (ft.) 24a. For All Wells: Submit tliis,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: I I
10.Static water level below top of casing: 300 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use••+" 1617 Mail Service"Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in,) 24b.For Infection Wellsi 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.) i
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 Supply&Iniectibn 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: 103 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
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