GW1--04656_Well Construction - GW1_20240809

-II 1111t 1 WSW
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: `
1.Well Contractor Information:
Travis Greene 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
0 n• 160 ft• isyP,,,
4238
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. 57 ft. 6 1/4 in. PVC
Company Name
JCH-096W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO D1:\METER 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
[3Geothermal(Heating/Cooling Supply) x3Residential Water Supply(single) ft. ft. in.
0IndustriallCommercial CiResidential Water Supply(shared) 18.GROUT
11Irrigation FROM I TO I MATERI M. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o R• 20 ft• Bentonite
Monitoring 0Recovery ft. ft.
Injection Well: ft• ft.
Aquifer Recharge [3Groundwater Remediation
19.S AND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier it \I TO \I tTERIAI. F\IPI.\CF\IFNT METHOD
Aquifer Test [3Stormwater Drainage I I. ft.
Experimental Technology 0Subsidence Control ft. ft.
[3Geothermal(Closed Loop) EtTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock Is pc.grain si.e.etc.,
QGeothermal(Heating/Cooling Return) riOther(explain under#2I Remarks) o R. 57 tt. Clay
4.Date Well(s)Completed:06/28/24 Well ID# 57 ft' 188 ft Granite •'a•..
5a.Well Location: ft. ft. 40f.1 10?-4
d y -
Edward &Donna Hall ft. ft.
Facility/Owner Name Facility 11)4(if applicable) ft. ft. "v"' " .'-,g iItgi
35 Ottinger Heights Waynesville 28786 ft. ft,
ft. ft.
Physical Address,City,and Zip
Haywood 7694-58-9042 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:
35.463 N -83.044 W
,,,A -,-.?''Ste- 06/28/24
6.Is(are)the well(s)I Permanent or IJTemporar� 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: DYes or xONo with ISA NCAC 02C.0100 or 1SA 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: 185 (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: 10 (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 29699-1636
I 3a.Yield(gpm) 15 Method of test: 2 hours 24c.For Water SuDDIV&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: HTH Amount: 27labs completion of well construction to the county health department of the county
where constructed.
Form(iW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016