GW1-2022-00974_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCWTION
Well Contractor Name
4238 0 rt. 60 ft. Ngp,
60 ft• 105 ft. 20gpm
NC Well Contractor Certification Number 15.OUTER CASING for 7u11_cased wells OR LINER if a livable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 tt. 43 ft. 61/4 in. Steel
Company Name
M C M-283W 16.INNER CASING OR TUBING(geothermal closed-loo
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) Oj Residential Water Supply(single) ft. R. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. 6entonite
Monitoring Recovery ft. R.
[Experimental
n Well:
er Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test [3Stormwater Drainage
Technology Subsidence Controlermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION(color,hardness soil/rock e, rain size,etc.ermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft. 43 ft clay
4.Date Well(s)Completed: 11/05/21 Well ID# 43 145 ft.
Granite
5a.Well Location:
Shane Shook
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1536 Willis Cove Rd Canton 28716 ft. rt. JA
Physical Address,City,and Zip ft. ft. i„t
Haywood 8668-99-4711 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:
35.585 N -82.804 W
'A� _-__�J 11/05/21
6.Is(are)the well(s)OIPermanent or Temporary Signature of Certified We 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 E)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:
S.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: 145 (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@I00') construction to the following:
10.Static water level below top of casing: 60 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 A (in.) 24b.For Iniection 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) 40 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: 25 Tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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