GW1-2021-06201_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 405 ft. 'gpm
2418
405 ft. 605 ft. eam
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. 42 ft. 61/4 in. SDR21
Company Name
M CM-261 W 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,County,State. Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) 0 ft. 42 ft. Clay
4.Date Wells Completed:09/21/21 Well ID# 42 tt 1 105 ft.
() p Granite
5a.Well Location: ft. ft. ocom
Matt Bare ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO
2504 Crabtree Mtn Rd Clyde 28721 ft. ft.
Physical Address,City,and Zip ft. ft' nWR SECTION
Haywood 8659-11-3161 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.C on
35.588 N 82.863
09/21/21
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 EJNo 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1,105 (ft.)
P 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 140 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: 2 Hours 24c.For Water Supply&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: 200 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 Revised 2-22-2016