GW1--07347_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: i
Travis Greene ,,
14.WATER ZONES -, ,
WeIlConttactorName FROM TO DESCRIPTION
4238 o ft. 250 ft. 29,m I
250 ft• 500 ft. 39,m
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased-wells)OR LINER(if ap Ucable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 119 J ft. 61/4 I in. PVC
Company Name
OSS-2023-0152 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, 1 in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN. - -
' '
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. ft. in'i
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in!+ '
Industrial/Commercial j Residential Water Supply(shared) 18.GROUT • '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- -20 ft• Bentonite
Monitoring DRecovery ft. .- ft.
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery I0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test jStormwater Drainage ft. ft. _
Experimental Technology f ['Subsidence Control ft. ft. i
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,soil/rock type grain size,etc.)
0 ft. 119 ft• Clay j
4.Date Well(s)Completed: 10/11/23 Well ID# 119 ft. 605 ft.
Granite '
5a.Well Location: ft. ft.
Tom Defrange ft. ft. 1 .-,_,_ _
Facility/Owner Name Facility ID#(if applicable) . ft. - �, `'`r'- '' '.
ft ;ls
3178 Butler Bridge Rd. Mills River 28759 ft. ft. I NU 2023
Physical Address,City,and Zip ft. ft. I
Y tY. P Il fC . ^ci ,,.-
Henderson 9632-84-4326
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:
35.413_ -82.563
N W
- 10/11/23
6.Is(are)the well(s) Permanent or Temporary Si ature of Certified Well Contractor Date
�X
By signing this form,I hereby certfbi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: !Yes or QNo 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.
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: 605 (fk) 24a. For All Wells: Submit this form!within 30 days of completion of well
For multiple wells list all depths!I-different(example-3@200'and 1@100') construction to the following: i
1
10.Static water level below top of casing: 80 (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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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: 109 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 1 ' Revised 2-22-2016