GW1-2021-07552_Well Construction - GW1_20210903

Rrint-For
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. 545 ft• 89pm
ft. ft.
NC Well Contractor Certification Number Inc15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Bros. Well & Pump, WT c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 54 ft. 6 1/4 ' in. ISDR-21
21100112454 16.INNER CASING OR TUBING eothermal 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. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) M Residential Water Supply(single) ft• ft, in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It' 20 ft. Bentonite
])Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
rl%Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology I3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM I TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0 ft. 54 ft- Clay '
4.Date Wells)Completed:08/06/21 Well ID# 54 fA 565 ft' Granite
Sa.Well Location:
ft. ft.
John & Linda Weaver ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
et car=IN r
7 Forge Mtn Rd. Mills River, NC 28759 ft. ft.
Physical Address,City,and Zip ft. ft.
3
Henderson 9620-77-8768 21.REMARKS
County Parcel Identification No.(PIN) 11 PromsAICIVI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Dw
(ifwell field,one lat/long is sufficient) 22.Certification:
35.364 N 82.622 W
jz�," &—,...--- 08//06/21
6.Is(are)the well(s)oPermanent or 13Temporary 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 iX No 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#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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 565 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:80 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 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) 8 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: 103 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