GW1--05087_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Travis Greene 14.WATER ZONES • -. • : _ °
FROM TO DESCRIPTION
Well Contractor Name
0 ft, 200 ft• ars gin I
4238
ft. ft.
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. 22 ft• 61/4 in. PVC
Company Name 16:INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:W 122120103266 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •'•FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural DMunicipal/Pubiic ft. ft. in.
*Geothermal(Heating/Cooling Supply) E3Resid enti al Water Supply(single) fL ft. in•
it Industrial/Commercial DResidential Water Supply(shared) 18..GROUT" s
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite
VI Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
%Aquifer Recharge Groundwater Remediation
• 19.SAND/GRAVEL PACK(if applicable) -
NIAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
%Aquifer Test DStormwater Drainage ft. ft.
*Experimental Technology E3Subsidence Control ft. ft.
III Geothermal(Closed Loop) (©(Tracer 20.DRILLING LOG(attach additional sheets if necessary) ' :. _..
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
I Geothermal(Heating/Cooling Return) IDOther(explain under#21 Remarks)
0 ft• 22 ft• Clay
p 07/20/23 22 ft* y� ft. Granite1(=�""'$,"�.' y
4.Date Well(s)Completed: Well ID#
ft. ft. k vi,t"..,..A re a A,�se✓
5a.Well Location:
Adam Toney ft. ft. AU.G 0 A 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft. t
It}�.t, (-..;�- 2ryr4,04l, Uri
Randy Dr. Hendersonville 28791 ft. ft. DViCer5t 3
Physical Address,City,and Zip ft. ft.
Henderson 9650-92-6715 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.Certification:
35.356 N -82.489 W .-.1. / 07/20/23
6.Is(are)the well(s)0Permanent or [ Temporary Signature of Certified Well Contractor' Date
By signing this form,1 hereby certj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or XjNo with 15A NCAC 02C.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#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: 985 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa200'and 2®100') construction to the following: ,
10.Static water level below top of casing: 600 (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) 3/4 Method of test: 2 hours 24c.For Water Supply&Inieiction 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: 180 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