GW1--03857_Well Construction - GW1_20240628

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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
O fL 305 ft. 344476tavm
2418
rt. it.
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
O ft. 45 ft. 61/4 in. Steel
Company Name
DM C-002W 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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XQResidential 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 45 ft. Bentonite Pumped full length grout
Monitoring DRecovery ft. ft.
Injection Well: -
ft. ft.
QAquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
QAquifer Storage and Recovery D Salinity Barrier FROM TO MATLRI II. EMPLACEMENT METHOD
QAquifer Test f'Stormwater Drainage ft. ft.
QExperimental Technology IDSubsidence Control ft. ft.
QGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) o ft. 45 ft. Clay
4.Date Well(s)Completed:05/17/24
Well Il)# as ft. 525 rt. Granite
5a.Well Location: ft. ft.
ft. fL r•�r
Richard Prefontaine EN .L L I;JE D
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
632 Mountain Cove Rd.Waynesville 28786 ft. ft. JUN 9 8 2024
Physical Address,City,and Zip ft. ft. (f..Jl1F6'►C "Mai' 1J44
Haywood 8625-98-3754 21.REMARKS f7A C.s SOG
County Parcel Identification No.(PIN) Pumped full length grout per variance
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one latllong is sufficient) 22.C 'fication:
35.496 N -82.934
l.Q - 05/17/24
6.Is(are)the well(s)>QX Permanent or [JTcmporaty Signature of Certified Well 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: QYes or 2 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:
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 (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:
10.Static water level below top of casing: 300 (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 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) 3/4(.75) Method of test: 2 hours 24c.For Water Supply& Iniection 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: 96 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