GW1--00871_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 165 ft.
2418 l
ft. ft.
NC Well Contractor Certification Number ' IS OTITER CASING(forri ultt-eased•wells)'DI :LINER(1£ap livable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 66 fL 61/4 j in' Steel
Company Name
J M Q-2 J41/V Ib INNER-CASItsIG 4R TUBIN6(geutheFoial 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.
3.Well Use(check well use): ft, ft. in.
17:'SCREEN
Water Supply Well: ._.
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ram° OMunicipal/Public ft. ft. ii•
Geothermal(Heating/Cooling Supply) DRnsidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18:GROAT
Irrigation FROM TO . ' MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. Bentonite
Monitoring DIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19SAND/GRAVEL.PACK(if applicable)
Aquifer Storage and Recovery (Salinity Barrier' FROM TO MATERIAL EMPLACEMENT METHOD '
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer : 20sDRILLINGLOG(attach=additional sheets ifnecessaty)=
-- FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rtOther(explain under#21 Remarks)
0 ft. 66 ft. Clay
4.Date Well(s)Completed: 11/07/23 Well ID# 66 it. 186 ft•
ft. ft.
Sa.Well Location:
Adam Hawkins ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. • '= v..-'li.,:-i..F: L.,., ,
Echo Dr. Waynesville 28786 ft. ft. F tt3 0 5 '2024
Physical Address,City,and Zip ft ft. t .�
Haywood 8604-34-7797 y
21:=REMAIfK5 ,..: r.,,: .- .,:. F;),.t : ,._
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:
35.454 N -83.018 W
11.rQ-A'''' 11/17/23
6.Is are the wells x Permanent or 1 Tem or re of Certified Well Contractor Date
Is(are) c) DU p
By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or IjNo 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 tire 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 INSTRUCTIONS4
9.Total well depth below land surface: 185 Oft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdifferent(example-3@200'and 2@100) construction to the following:
I
10.Static water level:below top of casing: �D it (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? 4 (m.) 24b.For Iniection 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]usb et )
• DivisiomofWater-Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS O SL' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 \Ictliod of test 21 s 24c For`WaterSimuly_&Tniection Wells: In addition to sending the form to
the addresses) t oye, also submit 1 one copy of this form within 30 days of
13b.Disinfection type: HTH Amotmt .>J completion of well constriction to
F, the county health department of the county
where constrected:' l
Form GW-I Nott6 a- eP�;i a cs E3+wuamental Quality-Division of Water Resources Revised 2-22-2016
'a;