GW1--05943_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 1a.WATER ZONES ,-
Well Contractor Name _FROM TO , DESCRIPTION
0 ft. 185 ft. a yam f
2418
185 ft. 285 ft. 9 pm
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. 45 ft. 61/4 i in. Steel
Company Name -
MCM-242W 16:INNER CASING-OR TUBING(geothermalclosed-loop) . -. C
2.Well Constriction Permit# lVl FROM TO DIAMETER THICKNESS MATERIAL
-
List all applicable well construction permits(Le.UIC,Count;State,Variance,etc.) ft. fL I in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 1.7.'SCREEN , :.. w• ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [jMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) '18.GROUT ' - • '
l Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Bentonite
Monitoring [Recovery ft. ft.
Injection Well: - —
ft. ft.
Aquifer Recharge OGroundwater Remediation -
19.SAND/GRAVEL PACK(if applicable) ,.
r Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) DITracer ,20.DRILLING LOG(attach additional sheets if necessary). .
_- FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) QlOther(explain under#21 Remarks) 0 ft. 45 ft. Clay
4.Date Wells Completed:07/17/23 Well ID# 45 ft. 305 ft. Granite
O P r"`:
5a.Well Location: ft. ft. .. �� C
Jim Patterson ft. ft. -— '
Facility/Owner Name Facility ID#(if applicable) ft. ft. ��D Y C U`
1124 Burnette Cove Rd. Canton 28716 ft. ft. ith`;r,Z^iCfl `:�.Kpa 1 ir.
9.
Physical Address,City,and Zip
ft. ft. Q i v�'1`s.;43
Haywood 8653-86-9578 ,21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
35.438 N -82.831 w /,4 J k
/� 07/17/23
6.Is(are)the well(s)4JPermanent or JTemporary Si v.r of Certified Well Contractor Date
By signing this foray,I hereby certU that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or No with 1SA 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3(4)200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (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) 15 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: 56 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