GW1--07353_Well Construction - GW1_20231113

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, WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I I
14.WATER ZONES-. r '
Robin Webb FROM TO DESCRIPTION
Well Contractor Name 0 ft. 265 ft• 6spp, I
2418 265 ft 385 ft* 4spm
NC Well Contractor CertificationNumber 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER r ` THICKNESS MATERIAL
o ft. I
72 ft. I
61/4 in.' I PVC
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Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
JMQ-182W FROM TO DIAMETERI , THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. .i"
List all applicable well construction permits(i.e.UiC,County.State,Variance,etc.) I
ft. ft. iin:
3.Well Use(check well use): 17.SCREEN
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Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
®'Agricultural DMunicipal/Public ft. ft. in. I
®I Geothermal(Heating/Cooling Supply) 'X Residential Water Supply(single) ft, ft. in. I I
aIIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
(Irrigation 0 ft. 20 ft. 8entonite
Non-Water Supply Well:
1I Monitoring ORecovery ft. ft.
Injection Well: ft ft.
nIAquifer Recharge EllGroundwater Remediation •19.SAND/GRAVEL PACK(if applicable)
NI Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL
EMPLACEMENT METHOD
SIAquifer Test 0 Stormwater Drainage
ft. ft. l'
*Experimental Technology D Subsidence Control
ft. ft. I ,
III Geothermal(Closed Loop) QTracer 20:DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Iii Geothermal(Heating/Cooling Return) EilOther(explain under#21 Remarks) o ft. 72 ft- Clay „ ,
4.Date Well(s)Completed: 10/09/23 Well ID# 72 ft" 405 ft- Granite
ft. ft.
5a.Well Location: ft. ft. I
Paul Knoop ft. ft.
Facility/Owner Name Facility ID#(if applicable)
• 223 Winding Branch Trail Clyde 28721 ft. ft. I p _,e,., "'' i:i'w''
• NQ V .1 .2021
Physical Address,City,and Zip ft ft.
21.REMARKS
Haywood 8711-94-3657
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County Parcel Identification No.(PIN) hit:;'d�..','..stG
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/long is sufficient) 22.C r tion:
35.649 -82.975 �h I 10/09/23
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Signals ofCertified� a ontrac or Date
6.Is(are)the well(s)jPermanent or °Temporary
By signing this form,I hereby certtfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or XjNo 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells 1 ,
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells. Submit this 1 form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
60
10.Static water level below top of casing: (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.)
Division of Water Resources,Underground Injection Control Program,
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FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: 2 hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm)'10 the address(es) above, also submit one copy of this form within 30 days of
HTH Amount: 74 tabs completion of well construction too the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc Is
Revised 2-22-2016