GW1--02064_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene _.14:WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 265 ft• 60 w,,, I
4238 ft. ft. I
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• 75 ft. 61/4 in. Steel
Company Name
G I 186`n, 16.INNER'CASING,OR TUBING(geothermal closed-loop)-
2.Well Construction Permit#: V V 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.'SCR)EN
FROTH TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) :Residential Water Supply(single) -- - ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
__ IrrigationFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite
DMonitoring DRecovery ft, ft.
Injection Well: ft. ft.
Aquifer Recharge Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage ft. it. •
Experimental Technology QlSubsidence Control ft. ft.
BGeothermal(Closed Loop) EITracer 20.DRILLING LOG(attach additional sheets if necessary) `>
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) mother(explain under#21 Remarks) 0 ft. 75 ft- Clay
4,Date Wells)Completed: 02/29/24 Well ID# 75 ft. 285 ft• Granite _
ft. ft. 1.. ':_ .,. ..-- ' f,
• .-,—
5a.Well Location: . ,.:;,_.k n r' 1: )
Joretta Singleton ft. ft. n p `
Facility/Owner Name Facility ID#(if applicable) ft. ft. H r R tI [U2tf
100 White Birch Ln. Canton 28716 ft. ft. nrk-Aii�.r:' ?••- ,,y
ft. ft. 4 vC:3'
Physical Address,City,and Zip
Haywood 8643-77-3365 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:
35.439 N -82.870 �/
n ems, SC) �-�
02/29/24
6.Is(are)the well(s){Permanent or ElTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: FYes or FNo 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: 285 (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: 180 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail SetviceiCenter,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.e.auger,rotary,cable,direct push,etc.)
i Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 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: 51 tabs completion of well construction to the county health department of the county
where constricted,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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