GW1-2023-02593_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIIPTI[ON
2418 0 ft- 265 rL 21v11
rt. rt. _
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licabte
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 87 ft. 61/4 in' PVC
Company Name
JMQ-291W 16.INNER CASING OR TUBING tetithermalclosed-too '
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT
Irri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring DRccovcry
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfrock e,grain size,etc.
Geothermal(I-Ieating/Cooling Return) i Other(explain under#21 Remarks) FROM
tt. 87 ft. Clay
4.Date Well 03/13/23 rt.s)Completed: Well ID# a7 305 rr. Granite
ft. ft.
5a.Well Location:
Saied Zangenhpour/Benchmark Bldrs ft. ft. H 2p3
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. 7
304 Anglers Ridge Waynesville 28786 ft. fr.
Physical Address,City,and Zip ft. ft.
Haywood 8606-26-4790 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 cation:
35.515 N -83.025 W
03/13/23
6.Is(are)the well(s)oPermanent or OTemporary signature ofCerttfied well Contractor Date
By signing this form,I hereby certify that the trell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or XINo with 15A NCAC 01C_0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#11 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: 50 Division of Water Resources,Information Processing Unit,
If inter 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(gpm) 25 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: 56 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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