GW1--04230_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
Travis Greene :.14:WATER ZONES ,
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 145 ft ,
4238 fr. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ticable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 73 ft. 61/4 in. PVC
Company Name 2021-21 535-9-1 1 204 16.INNER CASING OR TUBING(geothermal closed-loop). .
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. ft. in.
Water Supply Well: 17.SCREEN . .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
BAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft in,
DIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT, _ - "
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
OMonitoring 0Recovery ft. ft.
Injection Well: ft. ft.
_ Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ID Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
20.Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ID
Tracer 20.DRILLING.LOG(attach additional sheets if necessary)
ROM F TO73 DESCRIPTION(color,hardness,soil/rock type,min size,etc.)
Geothermal(Heating/Cooling Return) QlOther(explain under#21 Remarks)
0 ft. ft. Clay
4.Date Well(s)Completed: 05/11/23 Well ID# 73 ft. 185 ft. Granite
5a.Well Location: ft. ft.
Michael Dunn/Balsam Builders ft. ft.
ft. ft. r•,.,, -k..o f.,
-` L_
Facility/Owner Name Facility ID#(if applicable) • t.,,e II.-,,s 4Y1.7.
325 Bear Crossing Sylva 28779 ft. ft. I JL o e 202
Physical Address,City,and Zip
ft. ft. 3
Jackson 7683-73-1401 21.REMARKS. .Inf v,e...;':c, Pr-.-s-..:.. -,i
„y .1C
County Parcel Identification No.(PIN) l+{ldl14C-4a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.422 N -83.072 WI
����Jo� ./0.- _ 05/11/23
6.Is(are)the well(s)X Permanent or Temporary Si tore of Certified We ontractor Date
By signing this form,I hereby cert0,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,full 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft•) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following: 1
10.Static water level below top of casing: 80 (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 Injection 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) 60 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: 33 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
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