GW1--03035_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 80 ft, 85 a�^
4238
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a likable)
Greene Brothers Well & Pump. WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 ft. 61/4 in. PVC
Company Name
M C M-42 7 W 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XDResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite
Monitoring ®Recovery ft. ft.
Injection Well: ft. t.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO NIATFRIAI. : EMPLACEMENT METHOD
❑Aquifer Test D Stormwater Drainage ft. ft.
OExperimental Technology ()Subsidence Control ft. ft.
OGeothennal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock hype,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) o ft. 40 ft. Clay
4.Date Well(s)Completed: 03/20/24 Well ID# 40 ft' 125 ft' Granite -- .
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Sa.Well Location: ft. ft. .` C- • , ,° f•', 'N.
Hubert Cogburn ft. ft. MAY 2 0 2024
Facility/Owner Name Facility ID#(if applicable) It. ft.
56 Cogburn Dr. Canton ft. ft. Ir,': - a- ..
ft. ft.
Physical Address,City,and Zip
Haywood 8673-06-6523 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 -82.792 W 41"--4 03/20/24
6.Is(are)the well(s) Permanent or JTempor'ar} Signature of Certified Well Contractor UatC
X
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: QYes or 10 No with ISA NCAC 02C.0100 or ISA 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: 125 (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: 20 (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 Infection 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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8'5 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: 125 Tabs completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016