GW1--04234_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES:
Well Contractor Name FROM TO DESCRIPTION
o ft. 225 fL sspm
2418
225 ft, 425 ft. tgpm 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 - - -
Company Name � 0 ft. 57 ft 61/4 ; in. PVC
-16.INNER CASING OR TUBING,(geother
DGS-025W J-025 W (geothermal closed-loop): -
2.Well Construction Permit#: G J V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17:SCREEN_:"
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'jr Agricultural OMunicipal/Public ft. ft. in.
III'.Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft. ft. in.
*ilndustrial/Commercial OiResidential Water Supply(shared)
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft• Bentonite
aIMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
$IAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Ill Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
a I Aquifer Test 0IStormwaterDrainage ft. ft.
*Experimental Technology IOSubsidence Control ft. ft.
jill Geothermal(Closed Loop) QQTracer 20.DRILLING LOG(attach additional sheets if necessary);-':
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
j♦Geothermal(Heating/Cooling Return) 010ther(explain under#21 Remarks) 0 ft. 57 ft Clay
4.Date Well(s)Completed:05/23/23 Well ID# 57 ft• 505 ft' Granite
ft. ft.
5a.Well Location:
Adam Marks ft. ft. R "' w'' i - '
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft.
Harley's Cove Waynesville 28785 ft. ft. JUI i! t- 2023
Physical Address,City,and Zip ft. ft. tryfr.Tc;r4.1^'t 7rr-:.,F sr Una
Haywood 8710-64-5901 21.REMARKS. - DWri'viilC-- - .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - - — --
(if well field,one lat/long is sufficient) 2 ation:
35.621 N -82.986 W
La -S 05/23/23
6.Is(are)the well(s)1JPermanent or 'jITemporary Signature of Certified Well ContractorDate
By signing this form,I hereby certify that the xell(s)was(were)constructed in accordance
7.is this a repair to an existing well: jYes or EiNo with 1SA NCAC 02C.0100 or ISA 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:w 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 if different(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,
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:
(ie.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) 8 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: 92 tabs completion of well construction to Ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016