GW1-2021-03700_Well Construction - GW1_20210823

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Prnt Form
WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 0 ft225 ft. 69pm
ft. ft.
NC Well Contractor Certification Number T 15.OUTER CASING for multi cased wells OR LINER if a licable
Greene Bros. Well & Pump, W I Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 44 ft. 61/4 i in Steel
Company Name
N R H-2 55 W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Gist 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:
pp y FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) J Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 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 rASalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MStormwater Drainage ft. ft.
Experimental Technology rl Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatingtCooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft. 44 ft. Clay ';
4.Date Well(s)Completed:7/04�21 Well ID# 44 ft 245 ft. Granite
5a.Well Location: ft ft.
Reece Williams ft ft. ;
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
44
1521 Cove Creek Rd. Waynesville, NC 28785 ft. ft. , q
Physical Address,City,and Zip ft. ft.
Haywood 8700-41-3212 21.REMARKS t - t,c, On
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. rtificati
35.678 N 82.960 W
07/09/21
6.Is(are)the well(s)oPermanent or ]Temporary Signatur of ertified 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 [BNo 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 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: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 if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:5 (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 Injection 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.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)6 Method of test•2 hours 24c.For Water Suonly&IniectioIn 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources S Revised 2-22-2016
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