GW1--03032_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 o ft• 185 ft. ��
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if a iicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 fL 110 ft• 61/4 In. PVC
Company Name
J M Q-341 W 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. UK'•County.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weil: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XResidcntial Water Supply(single) ft. ft. in.
industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundvtater Remediation
Aquifer Storage and Recovery ll''''�SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
t._,�' FROM TO MATERIAL F,MPI.ACEMF,NT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 110 ft. Clay
4.Date Well(s)Completed: 04/16/24 Well ID# 110 ft• 205 ft.
Granite
5a.Well Location: ft. ft.
Brian &Jessica Timchula ft. ft. t
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 2 0 20?4
44 Wild Rock Ct. Clyde 28721 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8638-05-5677 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.569 -82.933N W
orarV /1 r f 04/16/24
6.Is(are)the well(s) X Permanent or TemP , Signa&Ceficd Well Contracto Date
By signing this form,I hereby certifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XONo with 15.4 NCAC 02C.0100 or 15A NCAC.01C.0200 Well Construction Standards and that a
If this is a repair,.fill out knownwell construction information and explain the nature of the cop-.'of this record has been provided to the well owner.
repair under#11 remarks section or on the buck of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiifferent(example-3(cu200'and 2(a,100') construction to the following:
10.Static water level below top of casing: (iO (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 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
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: 36 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