GW1--03858_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
We1lContractorName FROM TO DESCRIPTION
0 14 305 ft. 1n 15)9P,
2418
ft. ft.
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. 564 ft. 6 1/4 in. PVC
Company Name
J C H-0 76 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.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
117.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) x0Residential Water Supply(single) ft. ft. in.
lndustriallCommercial In Residential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 54 ft. Bentonite Pumped full length per variance
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO M\TFRt 61 E1tP1.-tCEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [j Subsidence Control ft. ft.
Geothermal(Closed Loop) D 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 tt. 54 ft Clay
4.Date Well(s)Completed:05/13/24 Well ID# 54 ft' 605 ft Grange rz ..- j`'3
5a.Well Location: ft. ft.
Joseph &Mary Pollman ft. JUN 9 8 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
202 Living Good Ln. Waynesville 28786 ft. ft.
; 043
Physical Address,City,and Zip ft. ft.
Haywood 7695-18-7529 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.Ce tion•
35.490 N -83.059 W
� 05/13/24
6.Is(are)the well(s)ElPermanent or lTemporar�' Signature of Certified Well C ctor Datc
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: 0 Yes or ©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 inlbrmation 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: 605 (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 1@I00') construction to the following:
10.Static water level below top of casing: 50 (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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2(.5) 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: 109 cabs 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