GW1-2021-00724_Well Construction - GW1_20211208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: k
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
p ft. gp ft. xyom
4238
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a li e
Greene Brothers Well & PUMP, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
0 fL 30 ft. 61/4 in• SDR21
Company Name
MCM-279W 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. ft. in.
3.Well Use(check well use): ft. rt. in.
17.SC
Water Supply Well: FR MBE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ink
Industrial/Commercial Ei Residential Water Supply(shared) 1g,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. gentonite
Monitoring Recovery
Injection Well:
ft. tt.
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
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rein size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks
0 [t. 30 ft. Clay
4.Date Well(s)Completed: 11/04/21 Well ID# 30 ft. 505 ft, Granite!
5a.Well Location:
Don &Susan Thomas
Facility/Owner Name Facility ID#(if applicable) ft. tt. DEC 2021
1330 Cattail Ln. Waynesville 28786 ft. ft. v
Physical Address,City,and Zip
Haywood 8646-12-9203 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:
35.507 N -82.892 W
_ 11/04/21
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 ONo 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:_' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
Ifwater 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
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13a.Yield(gpm) 2 Method of test: 2 Hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this for within 30 days of
13b.Disinfection type: HTH Amount: 92 tabs completion of well construction to form within
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
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