GW1--04651_Well Construction - GW1_20240809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft• 665 ft. 34)9,m
4238
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 'cable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 ft. 61/4 in. PVC
Company Name
J M Q-325W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le Ul('. (minty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O Agricultural QMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
0Industrial/Conunercial DResidential Water Supply(shared) 18.GROUT
Illrrigation FROM 10 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery OSalinity Barrier FROM TO M'ITFRIAI. ESIPI.ACE\IFST METHOD _
DI Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology DSubsidence Control ft. ft.
(JGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFS('RIPTION(color,hardness,soil/rock type,grain size•etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o tt. 40 ft• Clay
4.Date Well(s)Completed:07/23/24 Well ID# 40 ft Gas ft.
pGranite - _ ,
5a.Well Location: ft. ft. . • •..r 4.. ; ( L
Teresa Cooksey ft. ft. ,,i ih :I 9 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
424 Hawks View Dr. Canton 28716 ft. ft. - 1 '''" •'-g+'jp.
ft. ft.
Physical Address,City,and Zip
Haywood 8678-65-4699 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:
35.575 N -82.779 w
07/23/24
6.Is(are)the well(s)DPermanent or 0Temporary 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: Oyes or E2 No with/SA NCAC 02C.0100 or 15A 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:
S.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: 685 (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: 560 (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) 30gpm 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: 118 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