GW1-2021-01589_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Conti actor Information:
�t, , i I
Robin ,Ne'lbb 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
2418 0 ft. 205 ft' vzaam
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased(wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM To DIAMETER TIHCKNEss MATERIAL
0 ft- 44 ft. 61/4 in. SDR21
Company Name u
N RH-225W 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: R GJ V V 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Oi Residential Water Supply(single) ft. ft. Ini.
Industrial/Commercial 13Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring 3Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation 1.9.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [J Stormwater Drainage ft. ft. Y
J Experimental Technology Subsidence Control ft. ft. I
Geothermal(Closed Loop) ©(Tracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type, rain size,etc.
0 ft. 44 ft, Clay
4.Date Wells Completed:03/02/21 Well ID# 44 ft. 705 ft,
p Granite'
5a.Well Location:
Amado Tanquero ft. ft. r t. -'
Facility/Owner Name Facility ID#(if applicable)
ft, ft.
286 Yellow Rose Rd. Clyde 28721
Physical Address,City,and Zip
Haywood 8721-38-0473 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. ertift lion:
35.659 N 82.963 W C.
r 03/02/21
6.Is(are)the well(s)oPermanent or Temporary 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 P-JiNo 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 detail's:
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: 705 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 400 (ft•) Division of Water Res urces,Information Processing Unit,
Ifwater 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 toI 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) 1/2 Method of test: 2 Hours 24c.For Water Supply&Inie1ction Wells: In addition to sending the form to
the address(es) above, also sulimit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 127 Tabs completion of well construction to the -ounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016