GW1--00897_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
Travis Greene -14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
4238 o tt• 485 ft• 60gpm
ft. ft. ,
NC Well Contractor Certification Number 15.`OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 46 ft. 61/4 in. PVC
Company Name
WEL2022-00A Q "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.UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
('Agricultural DMunicipal/Public ft. ft. in.l '
I
1 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.l
®iIndustrial/Commercial DRcsidential Water Supply(shared) g 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 0_I,I,Groundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
$11 Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
"Aquifer Test 3Stormwater Drainage ft. ft.
"Experimental Technology (Subsidence Control ft. ft.
®I Geothermal(Closed Loop) DTracer ,-,20.DRILLING LOG(attach additional sheets if necessary) ` . .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) D Other(explain under#21 Remarks)
0 ft• 46 ft. Clay ,
4.Date Well(s)Completed: 12/05/23 Well ID# 46 ft• 505 ft' Granite '
ft. ft.
5a.Well Location:
Greg Medford ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Medford Branch Rd/246 Ron's Ridge Rd. Candler 28715 ft. ft. b,-,--( -1,,..,, ' .
Physical Address,City,and Zip
21.REMARI{S�• ,ft. ft. _ s, ,,;/
Buncombe 8695-27-2334 rid `202�
County Parcel Identification No.(PIN) 1R ._ ?�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DIA,O,'0,2
(if well field,one lat/long is sufficient) 22.Certification: "
35.499 . N -82.722 �,
'i1`be, , z 12/05/23
6.Is(are)the well(s)JPermanent or DTemporary Signature of Certified Well Contractor Date
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: EJYes or X)No with ISA 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 hack 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:
10.Static water level below top of casing: 140 (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 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
I
13a.Yield(gpm) 60 Method of test: 2 hours 24c.For Water Supply&InjectionlWells: 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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