GW1--03047_Well Construction - GW1_20230310

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene '14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 180 ft. 2p-
185 [t. 465
NC Well Contractor Certification Number "'1s.OUTER CASING for multi4a'sed wells OR LINER if a �licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 60 fL 6 1/4' in.
PVC
Company Name I&INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: SAS-226W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun),,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): n. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) M Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. Bentonite
D Monitoring [3Rccovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salini Barrier
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology EISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach"additional sheets if necessary)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock G grain size etc.)0 ft. 80 ft. Clay
4.Date Well(s)Completed:02/02/23 Well ID# 60 ft. 565 ft. Granite =
5a.Well Location:
Charles& Heidi Devries ft. ft. MAN
(
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. Rice iiF l 1 i+
555 Flying Hawk Trail Waynesville 28786 ft. ft. %mot dvlJ''i i:i
Physical Address,City,and Zip ft. fL
Haywood 7685-76-7179 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.Certification:
35.484 N -83.071 W
cJfeal;�, ,� 02/02/23
6.Is(are)the well(s)oPermanent or EITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the u•ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofilie copy ofthis record has been provided to the well 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: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following'
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) 4 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: 1os tabs completion of well construction tol 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