GW1--08039_Well Construction - GW1_20231214

'WELL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only: I
1.Well Contractor Information: 1
Robin Webb :14:WATERZONES '. '', . - ,; . ', ,
Well Contractor Name FROM TO DESCRIPTION
2418 o It 185 ft• tea,
ft. ft. I 1
NC Well Contractor Certification Number
-'15 OUTER CASING(for multi-cased wells)OR LINER(if ap livable) .
.Greene Brothers Well &Pump,WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 98 ft. 61/4! in. Steel
Company Name •
16.INNER CASING'OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: MCM-111 W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County State,Variance,etc.) ft. ft. in. •
3.Well Use(check well use): ff• ft, in.
Water Supply Well:
::17.SCREEN
. FROM TO• DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. �nfn•I
Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I. ; Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring QlRecovery 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 Stormwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft j
Geothermal(Closed Loop) OTracer _20.DRILLING LO G(attach additional sheets if necessary) -
- Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitlrock type,grain site,etc.)
0 ft• 98 ft• Clay 1
4.Date Well(s)Completed: 10/31/23. Well ID# 98 ft• 205 ft• Granite
5a.Well Location: ft. ft." �, — : ^� -)
Taylor McCurry ft. ft • ".��� "aw 1. V.' 4-r-w.C..
Facility/Owner Name . Facility ID#(if applicable) ft. ft. •1DEC 1 4 2U(3
111 Cherokee Trail Canton 28716 ft. ft.
Physical Address,City,and Zip ft. • ft. D Cy';C1:j
Haywood 8663-47-9361 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.Ce "on: '
35.441 N -82.811 W ( Q-
( � 10/31/23
6.Is(are)the well(s)JX Permanent or JTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or QNo 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 constriction details. You may also:attach additional pages if necessary.
drilled: • SUBMITTAL INSTRUCTIONS 1 ,
9.Total well depth below land surface: 205 (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: i
10.Static water level below top of casing: 15 (ft.)" Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'+" 1617 Mail Service denter,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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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: 36 tabs completion of well construction toy 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
1