GW1-2021-03927_Well Construction - GW1_20210823

Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft- 145 ft. 2gpm
145 IL 225 ft. 15gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased'Yells OR LINER if a livable
Greene Bros. Well & Pump, WT Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 107 ft 6 1/4 j i" SDR-21
WP 20-136 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft I in.
3.Well Use(check well use): ft I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.I
Geothermal(Heating/Cooling Supply) [DResidential Water Supply(single) fL ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/mck rain siu etc.
0 IL 107 ft. Clay
4.Date Well(s)Completed:7/30/21 Well ID# 107 IL 245 ft' Granite
�,% I ,
5a.Well Location: ft. ft J a�s .w
Bob Koerber/David Knight ft. ft.
Facility/Owner Name Facility ID#(if applicable) & ft.
Lost Mine Trail Lot 620 Brevard, NC 28712 ft. ft
Physical Address,City,and Zip ft. ft.
Transylvania 8594-61-1717 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) 22.Certification:
35.250 N 82.647 W
07/30/21
6.Is(are)the well(s) J Permanent or OTemporary Signature of Certified Well-Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constnucted in accordance
7.Is this a repair to an existing well: [)Yes or JDNo 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 page4o provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 Method of test:2 hours 24c. For Water Suvvly&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: 43 tabs. completion of well construction to°the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016