GW1--04652_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• 200 ft• 4 aim
4238
ft. rt.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p H. 67 ft. 6 1/4 1°• Steel
Company Name
J C H-086W 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. R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural 0MunicipalPublic ft. ft. in.
()Geothermal(Heating/Cooling Supply) xOResidential Water Supply(single) ft. ft. in.
oindustrial/Commercial 0Residential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite
°Monitoring DRecovery ft. ft.
Injection Well: R. ft.
Aquifer Recharge QGroundwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO NI%TERIAI. EMPLACEMENT METHOD _
IDAquifer Test 0Stormwater Drainage ft. ft.
OExperimental Technology 0Subsidence Control ft. ft.
()Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
()Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DES(RIPTIOS(color,hardness,soil/rock type,grain sire,etc.)
o ft. 67 ft• Clay
4.Date Well(s)Completed: 07/03/24 Well ID# 67 ft' 485 ft.p Granite
ft. ft.
5a.Well Location:
Haynes Land Trust ft. ft. _ %/�—iv,
Facility/Owner Nam, Facility 1D#(if applicable) ft. ft. -71U6 q y 2024
Canyon Dr. Waynesville 28786 ft. ft.
If.:L ''24-4 .I',},--fit
Physical Address,City,and Zip ft. ft. 31�ti
Haywood 8624-24-1328 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
35.453 N -82.956
;t4 �,�� 07/03/24
6.Is(are)the well(s)1xPermanent or QTemporar} Signature of CertifiedWel(Contractor I):u,
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 15A 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 421 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: 485 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (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) 4 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 t pc: HTH Amount: 89 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