GW1-2021-01832_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb -14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2418 0 ft. 245 ft. 29,m
245 rL 265 ft. zecm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
Greene Brothers Well & Pump, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
0 It. 45 ff 1 61/4 ' ia. SRD21
Company Name
W E L2020-00428 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. UIG County.State. Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
17.
Water Supply Well: FROME TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. tt. in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R. R. in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 R. Bentonite'
Monitoring DRecovery
Injection Well:
ft. ft.
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 e, rain size,etc.
Geothermal eating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 45 ft, Clay
4.Date Well(s)Completed: 04/16/21 Well ID# 45 ft. 305 ft' Granite
Sa.Well Location:
Robert Samide r`' f`' acn
Facility/Owner Name Facility ID#(if applicable) ft. ft.
140 Gavin Glenn Rd Weaverville
Physical Address,City,and Zip
Buncombe Unit
9773-58-3950 21.REMARKS 11
D\tVR 1 C1!
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,.one lat/long is sufficient) =-fry
on:
35.729 N 82.452 W
04/16/21
6.Is(are)the well(s)oPermanent or 13Temporary 1, uo lfe 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: ®Yes or EJNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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: 305 (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@I00') construction to the following:
10.Static water level below top of casing: 80 Division of Water Resotrces,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 27699-1636
13a.Yield(gpm) 4 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: ss Tabs completion of well construction to the county health department of the county
where constructed. f
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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