GW1-2021-03279_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Travis Greene o r-r-�g NI ED 14.WATER ZONES
Well Contractor Name �� FROM TO DESCRIPTION
p ft. 140 ft. 209P.
4238 J U L U 2 2021
NC Well Contractor Certification Number 15.OUTER CASING for mutt'-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WTnEs3tton processing Unit FROM TO DIAMETER THICKNESS MATERIAL
®WR..gPc1:on 0 ft. 58 ft. 61/4 in. Steel
Company Name
MCM-247W 16.INNER CASING ORTUBING(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. Al. .
3.Well Use(check well use): ft. ft, in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in!
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. PO ft. eentonite
Monitoring ®Recovery ft. ft.
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal eating/Cooling Return) Other(explain under#21 Remarks)
p ft. 58 ft• Clay '.
4.Date Well(s)Completed: 06/03/21 Well ID# 58 ft. 225 ft.
Granite
fL ft.
5a.Well Location:
Jason &Carla Smith
Facility/Owner Name Facility ID#(if applicable) ft. ft.
136 Bethel Dr Canton 28716
Physical Address,City,and Zip ft. ft.
Haywood 8645-21-7413 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:
35.477 N 82.888 W
6.Is(are)the well(s)OPermanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constricted in accordance
7.Is this a repair to an existing well: ®Yes or ONo 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#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: 225 (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: 40 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 A (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 27699-1636
13a.Yield(gpm) 20 Method of test: 2 Hours 24c.For Water Supply&Infection 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: 4o 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