GW1--06584_Well Construction - GW1_20231006

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. 345 ft. rzs, '
2418 F
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. 108 ft. 61/4 j Iu• PVC
Company Name
MCM-400W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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. I is
17.SCREEN;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. .
in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft.
I Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO •
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring D Recovery ft. ft.
Injection Well:
ft. ft.
I_
FROM
'Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
I_ Aquifer TestStormwater.Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock type,grain size etc.)
0 ft. 108 ft. Clay
4.Date Well(s)Completed:09/07/23 Wel1ID# i08 ft 365 ft Granite
5a.Well Location: ft. ft. r.,-7
it z t ;
Scott Cook ft. ft. ;., n.. `-' �-r .,.
Facility/Owner Name Facility lD#(if applicable)
ft. ft. OCT 0 V 2023
111 Riley Trull Rd. Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft. G W 1, 0C
Haywood 8645-76-5267 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) , tification•
35.492 N -82.872 W a` i)P—LLI 09/08/23
6.Is(are)the wells)JPermanent or JTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cart fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA 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. r
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: 365 (ft-) 24a. For All Wells: Submit thisl 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: 50 (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: 1
(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) 12 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: 67 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 j Revised 2-22-2016