GW1--03144_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14..WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. P05 ft.
4238
205 tt• 605 ft.
NC Well Contractor Certification Number "15:OUTER CASING'for multi-cased'wells OR LINER a`Ileable
Greene Brothers Well &Pump,WT Inc. FROM TO DIAMETER TBICIQVFSS MATERIAL
0 ft. 1 80 ft. 6114 in. PVC
Company Name
EH Z47O7 16:INNER CASING ORTUBING(ge
othermal closed-liio '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance•etc.) ft. ft. in.
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
PP Y FROM TO DLUIIETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) �X Residential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 M Bentonite
Monitoring Recovery fL ft.
Injection Well:
ft. ft.
E
er Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
r Storage and Recovery IOSalinity Barrier FROM TO MATERIAL EMPLACEMENT bfETHOD
r Test E3Stotmwater Drainage ft. ft.
mental Technology Subsidence Control ft. ft.
rmal(Closed Loop) EiTracer 20.DRILLING LOG attach additional sheets if riecessa
FROMTO DESCRIPTION color,hardness•soillrock e, in size,etaermal(Heating/Coolin Return) Other(explain under#21 Remarks)
0 ft. 80 fL Clay
4.Date Well(s)Completed:04/04/23 Well ID# 80 fL 705 ft. Granite
5a.Well Location: ft.
Norman Bayne rt. ft. '"
LJ
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY ® 2023
54 Cabbage Patch Saluda 28773 ft. fr.
Physical Address,City,and Zip C'40d`l�,'30G
Polk P5-93 21.REN L4,RKS' .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is suffrcicnt) 22.Certification:
35.228 N -82.333 W J . 04/04/23
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified We Contractor Date
By signing this form,I hereby certify that the ne/l(s)ivas(tivere)constructed in accordance
7.Is this a repair to an existing well: OYes or QNo ivith 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature oflhe copy ofdris 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-I 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: 705 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 140 (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) 1.5 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 127 tabs completion of we 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