GW1-2023-02604_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 DESCRIPTION
0 ft. 305 ft. zser>m
2418
305 ft• 385 ft. rupm
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 DIA I1 TER THICKNESS 11I TERIAL
0 ft. 71 ft. 61/4 1 I in. PVC
Company Name
2022-24030-9-12440 16:INNER CASING OR TUBING(geothermal 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: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft.
NGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
irripation FROM TO MATERIAL EMPLACEMENT METHOD&AINOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa ) .
Geothermal(Heating/Cooling Return) FjOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiurock type,gruin size,etc.
0 ft. 71 ft* Clay
4.Date Well(s)Completed:03/06/23 Well ID# 71 ft 405 ft, Granite
5a.Well Location: ft. tt.
Robert Jacobson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Soaring Eagle Mountain Rd. Sylva 28779
Physical Address,City,and Zip ft. ft. APR R
Jackson 7673-40-8319 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.C Ic lion:
35.413 N -83.113 W C I
03/06/23
6.Is(are)the well(s)OPermanent or OTemporary Signature&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 )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
y'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 ivell owner.
repair under#21 remarks section or on lire 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: 405 (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 2@100� construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifnater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Infection 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) 3.5 Method of test: 2 hours 24c.For Water Supply&Injection 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: 74 tabs completion of well construction,to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016