GW1--05951_Well Construction - GW1_20230912

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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
0 ft. 105 ft. 409m I '
2418 f
ft. It.
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. 52 ft. 61/4 I in' PVC
Company Name
M CM-40�W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
rtVl 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
in•Agricultural Municipal/Public ft. ft.
1`_ !Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
®'Industrial/Commercial 'X Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: , 0 ft. 52 ft. Bentonite' Pumped full lentgh
*Monitoring [Recovery ft. ft. `
Injection Well:
ft. ft.
*Aquifer Recharge IJGroundwaterRemediation
-19.SAND/GRAVEL PACK(if applicable)
all Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
all Aquifer Test JStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
*i Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ai Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 52 ft. Clay i
4.Date Wells)Completed:07/28/23 Well ID# '\ 52 ft• 205 ft' Ganite i —
5a.Well Location: ft. ft. ! `^;, t! L ►, r,,.•.;—)
Tim Singleton
ft. ft. n,.,ti./i....is tt' }lL,�
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E P 1 2 2023
7858 Cruso Rd. Canton 28716 ft. ft.
ft. ft. Inf::::Z::::1 Pr^".,�:t1r.g LIT
Z,,
Physical Address,City,and Zipl��'�Ol`PLIG
Haywood 8654-04-0686 '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.C • ation'
35.460 -82.862 �, -
N
Alt,L Q, 07/28/23
6.Is(are)the well(s)0Permanent or Temporary of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo _ with 15A NCAC 02C.0100 or i5A 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: 205 (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: 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 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) 40 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: 36 tabs completion of well construction to:the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016