GW1-2021-05988_Well Construction - GW1_20211008

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft, 145 R- 60epm
2418
rt. rt.
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 THICKNESS MATERIAL
0 ft• 40 ft. 61/4 in. I Steel
Company Name
SAS-052W 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,Count),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
I17.SCREEN
N
ter Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
gricultural ®Municipal/Public ft. ft. in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) in.i
ndustrial/Commercial [I Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 ft- 20 ft. Bentonite
Monitoring Recovery
ection Well:
quifer Recharge ®Groundwater Remediation19.SANDlGRAVEL PACK if a licablequifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test [3Stormwater Drainagexperimental Technology Subsidence Control eothermal(Closed Loop) 13Traeer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
eotbermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 40 ft, Clay
4.Date Well(s)Completed: 09/07/21 Well ID# 40 ft. 165 rL
Granite
ft. ft.
5a.Well Location:
Mark Bondurant rt. it.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
105 Creative Cove Canton 28716 ft. ft. DWR Sedon
Physical Address,City,and Zip
ft. ft.
Haywood 8668-17-9551 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 erti I lion•
35.579 N 82.827 W / —
L�/l" 09/07/21
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: ®Yes or ®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#11 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: 165 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 10 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 1/4 (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
e
13a.Yield(gpm) 60 Method of test: 2 Hours 24c.For Water Supply&Iniectit n 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: 2s Tabs completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016