GW1--04654_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
I.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 40 ft• 17
4238
40 ft• 125 ft. 20ypm ttsm 165'23 gpm
NC Well Contra:for 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. 26 ft. 61/4 in. PVC
Company Name
M C M-436 W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#l: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. It. in.
3.Well Use(check well use): R. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural °Municipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft, g, In.
OIndustrial/Comm ercial 0 Residential Water Supply(shared) 18.GROUT
nIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite
°Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge 0Groundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery °Salinity Barrier FROM TO M\TFRIAI. EMPLACEMENT METHOD
0Aquifer Test 0Stormwater Drainage ft. ft.
°Experimental Technology El 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. 26 ft. Clay
4.Date Well(s)Completed:07/12/24 Well ID# 26 ft. 185 ft' Granite
5a.Well Location: ft. ft. .;.`.r U` ► 'I f f..'"'j
Roy Henderson ft. ft.
/it" rr
Facility/Owner Name Facility iD#(if applicable) ft. ft. �J J 2044
25 Sorrells Cove Rd. Clyde 28721 ft. ft. If :r:,,,;:-,: ,,-,� ., i
jai
ft. ft.
DAt -t; Y
Physical Address,City,and Zip
Haywood 8647-69-5068 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:
35.554 �. -82.876
07/12/24
6.Is(are)the well(s)�x Permanent or DTentporary Signature o Certra ified____ ;2 d 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: fYes or x]No with 15A NCAC 02C.0100 or ISA 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (fG) 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:40 (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 Iniection 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) 60 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: 27 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