GW1--01070_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: • I
I
li
- Travis Greene 14.WATER ZONES r
Well Contractor Name FROM TO DESCRIPTION
0 ft. 300 ft. 50, I I
4238
ft. ft. I ;
NC Well Contractor Certification Number '15LOUTER CASING(for:multi-cas`ediwells)OR=LINER'(if hp bcable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER; THICKNESS MATERIAL
0 ft, 75 ft' 61/4 j; in• PVC
Company Name
^
W E L2 021-00309 •,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. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEN ."
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in!
Geothermal(Heating/Cooling Supply) DResidcntial Water Supply(single) ft. ft. in.I 1
(Industrial/Commercial DResidential Water Supply(shared)
II Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
®iMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if ;
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
%Aquifer Test DStormwater Drainage ft. ft.
11 Experimental Technology -1 i Subsidence Control ft. ft.
Geothermal(Closed Loop) OITracer 20.DifiLLINGLOG(attach additional sheets if necessary) .-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
I Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 75 ft• Clay
4.Date Well(s)Completed: 02/06/24 Well ID# 75 ft. 325 ft' Granite)
5a.Well Location: ft. ft.
Cathy Moore ft. ft. 1 R'L .1—"a'�' �{a..
ti ! ;'
Facility/Owner Name Facility 1D#(if applicable) ft. ft. i
-
35 Childers Rd. Candler 28715 ft. ft. I LI3 i 2 2024
Physical Address,City,and Zip ft. ft. }fftfil11P.gieta P'Gc 1i ifte t
Buncombe 8687-15-3082 •21.REMARKS;:;,. '' :,: , LANVOLSOG ;,
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: I 1
35.546 N -82.761 �, f. •!
CLL[V;Ar �,_ _.
02/06/24
6.Is(are)the well(s) •0X Permanent or Temporary Signature of Certified we 1 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: IIYes or XI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our 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: 325 (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@I00') construction to the following: i ,
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 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 ofithis form within 30 days of completion of well
12.Well construction method: construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.) I ,
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 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: 60 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 Resou ices Revised 2-22-2016