GW1-2023-02594_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb Ia:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft• 285 ft. 76Pm
2418
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. mom TO DIAMETER THICKNESS MATERIAL
0 fL 77 ft. 6114 , in. Steel
Company Name
MCM-375W 16.INNER CASING OR TUBING �,eothertnal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell 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 E3MunicipaUPublic it. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. iu.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT .
I_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
- Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATF.RIAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control R. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)`
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock typ4 grain size,ctc)
0 ft. 77 ft, Clay
4.Date Weil(s)Completed:02/24/23 Well ID# 77 ft. 305 tt. Granite !--' "` -•
5a.Well Location:
Jeff Heatherly ft. ft. APR 1 0 7023
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
17 Bear Hunter Dr. Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8663-31-1599 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) �70
35.425 N -82.816 �, 02/24/23
6.Is(are)the well(s)OPermanent or DTemporary Siguature of Certified Well Contractor Date
By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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#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: 305 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
f 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(gpm) 7 Method of test: 2 Hours 24c.For Water Suably&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.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016