GW1--04199_Well Construction - GW1_20230706

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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
0 ft. 425 ft• egv.
4238
ft. ft. I
NC Well Contractor Certification Number
15:OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL -
0 ft. g0 ft. 61/4 in. PVC
Company Name
CJH-009 n, 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: fl .7 V 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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IJMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. fL in.
i Industrial/Commercial jResidential Water Supply(shared) :10.GROUT• -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary)'' •
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size etc.)
0 ft. 90 ft. Clay
4.Date Well(s)Completed:06/07/23 Well ID# 90 ft. 465 ft. Granite
5a.Well Location: ft. ft. „+E F..""_a ±/E D
Raymond&Elizabeth Schaub ft. ft. 2
Facility/Owner Name Facility ID#(if applicable) ft. ft. J IJ` C "'(�
��
711 Rustic Rd.Waynesville 28786 ft. ft. in;i rr:: cn Pi'c?': t;2:r:�Uril
Physical Address,City,and Zip ft. ft.
LJt:4.Q;c4."i
Haywood 8613-49-7818
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:
35.443 N -82.980 �, n
Le,0 15 R . 06/07/G3
6.Is(are)the wells)�X Permanent or jITemporary Signature of Certified W 11 Contractor Date
By signing this form,I hereby cert f that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONO with 15A NCAC 02C.0100 or 15,4 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#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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 300 (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 27699-1636
13a.Yield(gpm) 6 Method of test: 2 hours 24c.For Water Supply&Infection 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: 85 tabs completion of well construction to I th'e 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