GW1--01038_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
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Travis Greene , 14.WATER ZONES:-. ,:_ " • `"''-
We1lContrac[orName FROM TO DESCRIPTION
0 ft• 100 ft• 12,
4238
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• 52 ft• 61/4 I, in• PVC
Company Name
Cfss•-2023-1784 16.INNER CASING OR TUBING(geothermal - --.
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 • DMunicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) ;Residential Water Supply(single) ft. ft. in'.
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Residential Water Supply(shared)IndustriallCommercial
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK,(if;applicable)` -
Aquifer Storage and Recovery Ei Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology El Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20:DRILLING LOG(attach additional sheets im'necessary) ',j
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 52 ft. Clay 1;
4.Date Well(s)Completed: 01/10/24 Well ID# 52 ft• 185 ft Granite'
5a.Well Location: ft. ft. V, :.. „•rr ,-,.^
Cottages at Byron Forest ft. ft. • " L L g vi...
Facility/Owner Name Facility ID#(if applicable) ft. ft. I-
r
100 Byron Forest Dr. Mills River 28759 ft. ft. f1M,r 2 2024
t`I'.=.iF'1,fir C, ;'
Physical Address,City,and Zip ft. ft. i Dr �Wet
Henderson 9630-70-6865 `.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.Certification:
35.346 N -82.562 �, I
„lea, • c i 01/10/24
6.Is(are)the well(s) '�IX'Permanent or ®'Temporary 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: )Yes orONo 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 construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit tliis 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: 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServiceICenter,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
(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) 12 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: NTH Amount: 27 Tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016