GW1-2021-02607_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I � 1
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION I
2418
0 ft- 365 ft. sgPm W
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Tor multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 60 ft. I 61/4 in. !I SDR21
Company Name •
NRH-238W 16.INNER CASING ORTUBING eothermaljdosed-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.
I
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER': SLOTSIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) Oj Residential Water Supply(single) m!y
Industrial/Commercial Residential Water Supply(shared) t
18.GROUT
Irrigation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. gentonite
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
1.9.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater 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(Heating/Cooling Return) Other(explain under#21 Remarks 0 ft. 60 ft, Clay
i
4.Date Well(s)Completed: 03/22/21 Well ID# 60 ff• 385 ft• Granite'
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5a.Well Location:
Peter& Helen Borcherds
Facility/Owner Name Facility ID#(ifapplicable) c^� ?�� y�
919 Rockmont Rd. Waynesville 28785 ft. ft. a y1
Physical Address,City,and Zip ft. ft.
Haywood 7699-55-0203 21.REMARKS
County Parcel Identification No.(PIN) �10f1t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' on:
35.593 N 83.053 W �
03/22/21
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: [3Yes or E]No with 15A NCAC 02C.0100 or 15A NCAC 01C.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
depth below land surface: 385 9.Total well de (ft)
p 24a. For A11 Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths iit dierent(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 Mail Service enter,',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) 5 Method of test: 2 Hours 24c.For Water SUDDIV&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: 71 Tabs completion of well construction)to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resour�es1 Revised 2-22-2016