GW1--06585_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information:�
�lti V i 5 ( ir& '.:•,14.WATER ZONES �'
FROM TO DESCRIPTION
Well Contractor Name 0 ft• 405 ft. xom
Cf 2387 I ft. ft. I
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 I MATERIAL
0 ft. 32 ft. 61/4 ! in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:J MQ-315W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
ft. ft. in.
3.Well Use(check well use): I '
17.SCREEN
Water Supply Well: • FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural JMunicipal/Public ft. ft. in:
I
in.:Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft.
Industrial/Commercial L- Residential Water Supply(shared) 18.GROUT
- - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation
Non-Water Supply Well: 0 it• 20 ft• Bentonite
Monitoring DRecovery ft. ft.
Injection Well: • ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test tJ Stormwater Drainage ft. ft.
3Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 20.DRILLING LOG'(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 32 ft. Clay
09/07/23 32 ft• 605 • ft• Granite •
4.Date-Well(s)Completed: Well ID#
ft. ft. - i; r}
5a.Well Location: . - : ' .- .
Kevin & Karen Drury ft. ft. 't.;,_- ., -_-,'' V —L
Facility/Owner Name Facility tD#(if applicable) ft. ft. •
!1CT 0
6 2
3
508 Blake Dr. Canton 28716 ft. ft. t)
ft. ft. 11 i �t :`. - -.:•..
Physical Address,City,and Zip r< : .:`,UG
Haywood 8677-05-4647 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:
35.547 N -82.798 W 09/07/23
ire
!/.>el/6.Is(are)the well(s) Permanent or Temporary S of Certified Well Contractor Date
i=.4
- By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XNo 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 II
i
9.Total well depth below land surface: 605 (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: 140 (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 C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 2 hours 24c.For Water Supply&Iniectitin 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: 109 tabs completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016