GW1-2023-02605_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb "14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft- 145 ft. ]ospm
2418 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. 43 ft. 61/4 in. PVC
Company Name
2023-24465-9-12654 16.'INNER CASING OR TUBING eothermA closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAIIIETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. iIn•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
R
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. PO tt. eentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
I Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION color,hardness,soil/rack G rain size,ere.)
Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) 0 ft. 43 ft• Clay
4.Date Well(s)Completed: 03/09/23 Well ID# 43 ft. 165 ft• Granite
5a.Well Location: ft. ft. j
Gene Slay
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. APR
202 Roadrunner Dr. Sylva 28779 ft. ft.
Physical Address,City,and Zip
Jackson 7683-46-9027 .21.REMARKS-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 2 erti6ea'on:
35.429 N -83.079 W
03/09/23
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCertified 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 FXINo 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 of the copy of this record has been provided to the ivell 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: 165 (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@100D construction to the following:
10.Static water level below top of casing: 30 (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 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(,-pm) 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: 29 Tabs completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016