GW1--02163_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information: , '
Robin Webb ',14:WATERZONES _
Well Contractor Name FROM TO DESCRIPTION
2418 o ft. 305 ft. 2 I I'
305 ft• 405 ft. lgpm I 1
NC Well Contractor Certification Number 15 OUTER CASING(forinulti cased'wclls)ORLINEW(if applicable) `
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 22 ft. 6 1/4I 1 in. l PVC
Company Name
16.#INNERCASINGOR.TUBING9`(geothermal'closed-loop) -z
2.Well Construction Permit#: 2023-25768-9-13261 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. 1 i in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN r
!Agricultural FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
gri OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
:ISsGROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 tt. Bentonite
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK.(if applicable);-
Aquifer Storage and Recovery Salinity Barrier FROMTO MATERIAL EMPLACEMENT METHOD
Aquifer Test JStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20.'DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/roek type,grain size,etc.)
Geothermal(Heating/Cooling Retum) I Other(explain under#21 Remarks) 0 ft. 22 ft Clay
4.Date Well(s)Completed: 03/19/24 Well ID# 22 ft. 505 ft. Granite)
ft. ft.
5a.Well Location: •
Ken Thompson ft. f
I, �" " ' m,
o `i tft. =
Facility/Owner Name Facility ID#(if applicable) ft. ft. Aflf\ L024
607 Spruce Patch Ln. Sylva 28779 ft. ft. ln1::;; ...^a ^_ c.:. ]..,
t4
lt1 lY
Physical Address,City,and Zip ft. ft. G vt.,i 30G
Jackson 7674-97-5345 :21REMARKS ..;.
County Parcel Identification No.(PIN) I
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 er'ication: I,
35.459 N -83.098 W
"1-aQ, � 03/19/24
6.Is(are)the well(s)JPermanent or Temporary Signs re of Certified ell I Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or ®X No 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 wellidetails:
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:t 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: 80 (ft.)
Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ce iter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 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: j
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 2 hours 24c.For Water Supply&Injection)Wells: In addition to sending the form to
the addresses) 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 Revised 2-22-2016