GW1-2023-02592_Well Construction - GW1_20230410

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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 2418 ft. agwo I
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 DIAMETER THICKNESS MATERIAL
0 ft. 65 ft. 1 61/4 in. I PVC
Company Name
16.INNER CASING OR TUBING &othermal closed-loop)
J MQ-124W
Z.WCII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.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 DMAIETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft_ ft. to.
IndustriallCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. eentonite
Monitoring E)Rccovery ft. ft.
Injection Well:
_
( Aquifer Recharge Q Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
1 Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)"
Geothermal(Heating/Cooling Return) ( Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUmck t C min size eta)
p ft. 65 ft. Clay
4.Date Well(s)Completed:03/07/23 Well ID# 65 ft. 185 ft. Granite
5a.Well Location: ft. ft. �~
Keith Crawford ft. ft. r`
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR ! a
250 McElroy Cove Rd. Waynesville 28785 ft. ft.
Physical Address,City,and Zip ft. ft. '
W l�
Haywood 8628-05-9699 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Feld,one laUlong is sufficient) 22.C lea'on•
f)'
35.569 N -82.966 W
C 4>— 03/07/23
6.Is(are)the well(s)�IX Permanent or Temporary igtature of Certified 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: E)Yes or QNo 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 ofthe copy oftbis record has been provided to the Tvell 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: 185 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(erample-3 r@2ii000''and 1@I00) construction to the following:
10.Static water level below top of casing: "4 U (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:
.e.auger,rotary, construction to the following:
(�r ,g tary,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) 30 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 OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016