GW1--06581_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Robin Webb 14.WATER ZONES
Well Contractor Name . FROM TO DESCRIPTION
0 ft- 145 ft. 2,5g,
2418 145 ft. 165 ft. ,sm. t
NC Well Contractor Certification Number '15 OUTER CASING(for multi-cased wells)OR LINER(if ip'1[cable)
Greene Brothers Well & Pump,WT Inc. FROM TO DIAMETER ,THICKNESS MATERIAL
0 ft. 45 ft. 61/4 ! m. Steel
Company Name
16..INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2021-20619-9-12250 FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): rt. ft. to
"17.SCREEN ,..
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
%Agricultural DMunicipal/Public ft. ft. fn.'
$i Geothermal(Heating/Cooling Supply)'- Residential Water Supply(single) ft. ft in.
al Industrial/Commercial . DResidential Water Supply(shared) 18.GROUT ,
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Bentonite'
NiMonitoring DRecovery ft. ft. (
Injection Well: -
Ili Aquifer Recharge Groundwater Remediation ft. ft.
-19.SAND/GRAVEL PACK(if applicable)
%Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*IAquifer Test IIStormwater Drainage ft. ft. 1
all Experimental Technology [ Subsidence Control ft. ft. i
ill Geotherral(Closed Loop) J Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO ) DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
I Geothermal(Heating/Cooling Return) EllOther(explain under#21 Remarks)
0 ft. 25 ft. Clay 1
4.Date Well(s)Completed:08/22/23 Well ID# 25 ft 185 ft' Granite
ft. ft. 1. by n
5a.Well Location: o ., 'ir..R",9 'i f R—ii-'?�
Derek Detring/Eagle Nest Mtn.Cons[. ft. ft. �" s
Facility/Owner Name Facility ID#(if applicable) ft. ft. OCT V 20Z3
55 Native Trout Dr.Tuckaseegee 28783 ft. ft. Irt3,r�.4icn Prcv^..��2:-: 1,t,S.
Physical Address,City,and Zip ft. ft. G 't.v 'r tz
Jackson 8516-28-2872 2r REttMRICS '>. '
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.Ce l b<lion:
35.261 N -82.977 W •
LQ ("S
08/22/23
6.Is(are)the well(s) (Permanent or [(Temporary Signature�f Certified Well Contractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with I5A 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: 185 (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: 1 (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.) I 24b.For Iniection Wells: In iddition 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&Iniection 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-I , North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016