GW1--07342_Well Construction - GW1_20231113

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb 4 14.WATER ZONES
We1lContractor Name FROM TO DESCRIPTION
0 ft. 305 ft. so. I 1
2418
305 ft• 485 it• 5gpm r
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if ap Rcable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 85 ft. 61/4 1 in. PVC
2021-20825-9-12165 . 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,County,State.Variance.etc.) ft. ft. i in.
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3.Well Use(check well use): ft. ft. , °'
`17i SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EtMunicipal/Public ft. ft. In.,
Geothermal(Heating/Cooling Supply) ;x Residential Water Supply(single) ft. ft. in•'
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
_. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring Ditecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft. ft.
Experimental Technology QlSubsidence 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) ; Other(explain under#21 Remarks)
0 ft. 65 ft. Clay
4.Date Weil(s)Completed: 09/29/23 Well ID# 65 fte 505 _ft' Granite
5a.Well Location: ft. ft.
ft. ft. I;- ;
Izzie Properties LLC/Jeff Moralesf `� .;'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
LT. 29 Parkway Sec. Maggie Valley 28751 ft. ft. ���V 1 ZQZ3
ft. ft. � ' Iriiv'ii7, "'il 1,'-,..Y--.•,-I
Physical Address,City,and Zip _ ; :,
Jackson 7665-25-4569 i 21.REMARKS t- �_,.: ;'::;
County Parcel Identification No.(PIN) I
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
35.479 -83.158 r
N w' 09/29/23
6.Is(are)the well(s)JX Permanent or QlTemporarySiyØ'. J41eLW—
of Certified Well Contractor Date
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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: f Yes or 3No 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
9.Total well depth below land surface: 505 (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:
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10.Static water level below top of casing: 120 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/4 i '
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of'ithis 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) 10 Method of test: 2 hours 24c.For Water Supply&Injel lion 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: 92 tabs completion of well construction)to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016