GW1-2021-07622_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4238 o rt. szo rt.
rt. ft.
NC Well Contractor Certification Number �n/T 15.OUTER CASING for multi-cased wells OR LINER H a licable
Greene Brothers Well & Pump, VV I Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 84 ft. 61/4 in' SDR21
Company Name
W P 18-079 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt g, 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 13Recovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock type, rain size,etc.
Geothermal(Heatin Cooling Return) (explain under#21 Remarks) 0 ft. 84 ft. clay
4.Date Well(s)Completed:08/05/21 Well ID# 84 ft 625 ft Granite
5a.Well Location: ft. ft. CON
Layne Barber/Sundog Homes(James Browning)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Mountain Home Trail Lot 78 Brevard 28712 ft. ft. �ggm
Physical Address,City,and Zip ft. ft. 1n1a1V,3
Transylvania 8574-85-2711 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.Certification:
35.192 N 82.755 W ,
-11 , 08/05/21
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 ®No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0100 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-I 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: 625 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 1@I00') construction to the following:
10.Static water level below top of casing: � (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) 100+ Method of test: 2 Hours 24c.For Water Supply&Iniection 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: 113 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016