GW1--03878_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb `14:WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
2418 o fL zos It. Aga„
205 It, 460 ft. s
NC Well Contractor Certification Number 151 OUTER CASING for multi-cased ivelis OR LINER d a licable
Greene Brothers Well &Pump, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft- 22 ft. 61/4 , in PVC
Company Name
J M Q-217W 16:INNER CASING OR TUBING(geothermal closed-loo .
2.Well Construction Permit#: IVI G 1I V 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): fL ft. in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAIIIETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [jMunicipal/Public fL ft. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Olikesidential Water Supply(shared) 18:GROUT "`
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 6entanite
Monitoring ORecovery ft. R.
Injection Wl:
Aquifer Reelcharge JDGroundwater Remediation
c°19.SAND/GRAVEL PACK-(if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if nekessa
FROM TO DESCRIPTION color,hardness•soil/rock type in sue,etc
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks)
0 ft. 22 ft* Clay ,
4.Date Well(s)Completed:04/27/23 Well ID# 22 ft. 505 ft, Granite
5a.Well Location: ft. ft.
Brad &Anna Morgan ft. ft. JUN 9 2023
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �sa "—
1074 Sugar Cove Rd. Clyde 28721 ft. ft.
Physical Address,City,and Zip ft. fL
Haywood 8733-74-6890 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.C titiea' n•
35.706 N -82.916 W
04/27/23
6.Is(are)the well(s)oPermanent or !©ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the uvil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or QC No with 15A NCAC 01C_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 well owner.
repair under#11 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 I 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(erample-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 60 (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(gpm) 1 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: 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 Revised 2-22 2016