GW1--03863_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1.Well Contractor Information:
i
Travis Greene j,14..WATERZONES "
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. IO
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells ORLHHER a ilcable
Greene Brothers Well & Pump,WT Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 40 ft. 61/4 in. PVC
Company Name A G
2021-20513'9-12436 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIG County,Stale,Variance,etc.) It. ft. in.
3.Well Use(check well use): fit. fit. in,
Water Supply Well: -.17.SCREEN
FROM TO DWITER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public fit. fit. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. tu,
Industrial/Commercial [IResidential Water Supply(shared) -18.GROUT '
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 9entonite
Monitoring Recovery ft. ft.
[Experimental
n Well:
ft. ft.
er Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test 3Stormwater Drainage fit. it.
Technology 0Subsidence Control ft. fit.ermal(Closed Loop) I©ITracer 20.DRILLING LOG(attach additional sheets ifnecessa ermal(Heatin Coolin Return FROM TO DESCRIPTION color,hardness,seiVrock 4 grain size•etc.
g/ g ) Other(explain under#21 Remarks)
0 ft. 40 ft. Clay
4.Date Well(s)Completed:05/17/23 Well ID# 40 ft.ft. 505 ft, Granite
ft. 'I rl Jam,4D
5a.Well Location: ���� 0_6`"�'
Douglas Gray
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Spruce Patch Ln. Sylva 28779 ft. ft. Pr.=!"U1IVI
Physical Address,City,and Zip ft. ft.
Jackson 7674-96-7808 'i21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.457 N -83.098 W
05/17/23
6.Is(are)the well(s)OPermanent or [3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the w•ell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: (QYes or X)No with 15A NCAC 01C-0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iftlris is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of dds fornn.
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: 505 (fit•) 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:40 (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 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 276994636
13a.Yield(bopm) 2 Method of test: 2 hours 24c.For Water Supply&Iniection Wells: In addition to sending the fort to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 92 tabs completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22 2016