GW1--05315_Well Construction - GW1_20240906

I l ll It 1 VI l l!
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 225 ft. so
4238
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(if a licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 53 ft. 61/4 in, PVC
Company Name
M C M-431 W 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. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ID Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ts.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonite
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test
Salinity Barrier FROM TO MATERIAL
20. METHOD
Stormwater Drainage ft. ft.
Experimental Technology C)Subsidence Control ft. ft.
Geothermal(Closed Loop) DTrac(r 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO i DVS('RIFTION(color,hardness,soil/rock type,grain.sire.etc.(
0Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) o ft. 53 ft. Clay
4.Date Well(s)Completed: 07/29/24 Well ID# 53 it 245 ft* Granite
5a.Well Location: rt. rt. r•- 7"--,
" e.• t j
Wagon Gap LLC ft. ft. - l'` LI L ';/!�;
Facility/Owner Name Facility ID#(if applicable) ft. ft. C[D..,[1-
r 0 6 2024 �!
Wagon Gap Trail Canton 28716 ft. ft.
ft. ft. in4orn ,,, ,1 1:)'''.� -r
Physical Address,City,and Zip aNr u2
Haywood 8661-56-1134 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35.384 N -82.811 W
07/29/24
6.Is(are)the well(s)Ox Permanent or alemporary 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 E2 No with 1SA 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (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: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall 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) 60 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: as cabs 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