GW1--04158_Well Construction - GW1_20240717

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jamison Gibson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4093-A 0 11- 260 rL Hollow
260 n• 325 n• Hollow
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Appalachian Well Drilling, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ri. ft. in.
Company Name
2023-00522 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. UDC,County,State,Variance,etc.) 0 n• 144 it. 6.25 in' SDR21 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Mun' pal/Public 0 ft- ft. DIAMETER
Geothermal(Heating/Cooling Supply) Vitt-pal/Public
Water Supply(single) n. ft. in.
Industrial/Commercial Residential Water Supply(shared) lg.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 n• Betanite Pour _
°Monitoring 0 Recovery ft. iL Chip
Injection Well: a
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery InSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage n. n.
aExperimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 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)
0 ft- 14 n• Clay/Overburden
4.Date Well(s)Completed: 6/10/24 Well ID# 14 n• 40 ft- Granite
5a.Well Location: ft. ft. r - '_..• r--
2020 builders ft. ft. I'-,L 5,.'.,.. V I- il...
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 I II 1 20 2 T
13 Greenridge Road, Weaverville, NC 28787 ft. ft.
Physical Address,City,and Zip ft. ft. Iri.,:'A.. 1.::.-) '1Jf)z
Buncombe 97338794420000 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.Certi cation: •
35 43 24.186 N 82 34' 31.577" •
6-10-24
6.Is(are)the well(s)fmanent or E3Temporary a of Certified well Con ac or 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 Yes or o with 1 SA NCAC 02C.0100 or 1 SA 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: 405 (D•) 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@/00) construction to the following:
10.Static water level below top of casing: 120 (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: 6.25 (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) 12 Method of test: Gal. bucket 24c.for Water SuDDly& 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: Chlorine Amount: 4 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