GW1-2023-02589_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Robin Webb '14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
0 M 165 ft. 8gPm
2418
ft. ft.
NC Well Contractor Certification Number
"15:OUTER CASING for multi-casedwetls OR LINER if-a licable
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 46 ft. 61/4 , ;in PVC
—q pcW ` 16.INNER CASING OR TUBING( eothermal closed-loo M�
2.Well Construction Permit#: M 386 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.. .- r'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fG in.
- Industrial/Commercial OResidential Water Supply(shared)
-18:GROUT'
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Bentonite
Monitoring Recovery ft. ft.
[— mental
n Well:
ft. ft.
er Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a' licable)
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test DStormwater Drainage ft. ft.
Technology Subsidence Control ft. ft.
ermal(Closed Loop) QlTracer 20:DRILLING LOG(attach additional sheets,if necessaFROMTO DESCRIPTION color,hardness,soiVroek 4 in size,etc.)
ermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 48 ft* Clay
4.Date Well(s)Completed:02/07/23 Well ID# 48 ft. 205 ft" Granite
Sa.Well Location: ft. ft.
Jeanne Colburn ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
670 Coffee Branch Rd. Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8655-37-0025 '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.C u on
35.494 N -82.854 W
02/07/23
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rrell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or 'XX No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,full out known well construction information and explain the nave ofthe 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.
filled'r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q200'and 2Q1001 construction to the following:
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) 28 Method of test: 2 Hours 24c.For Water Supply&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: as 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