GW1-2021-02071_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�� / ft. ft.
2418 �y C i 65 10°9v" 4
fa ft. ft. � ,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. JUL 0 9 20 FROM TO DIAMETER THICKNESS MATERIAL
tft. 48 ft' 61/4 in. Steel
Company Name lnf o rr2tiOn Process
SAS-159W �+ 6.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: D1IVR SectlO 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 ®MunicipaUPublic
Geothermal(Heating/Cooling Supply) OI Residential Water Supply(single) ft. ft. in
Industrial/Commercial DResidcntial Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 20 tt Bentonite
Monitoring Recovery
Injection Well:
ft, tt.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sir,etc.
0 ft. 48 ft, Clay
4.Date Well(s)Completed: 06/22/21 Well ID# 48 ft 105 ft Granite'
5a.Well Location:
Joseph Kincart
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
38 Imperial Court Waynesville 28785 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 7688-78-3039 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. rtiric 'on:
35.572 N 83.077 W
E 06/22/21
6.Is(are)the well(s)1I Permanent or Temporary Signature o Certified Well 55@ctor 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill and 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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (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
13a.Yield(gpm) 100 Method of test: 2 Hours 24c.For Water Supply&Infection Well's: 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: 16 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