GW1-2021-02072_Well Construction - GW1_20210702

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:Tad Thompson MEC , l
�+E 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4364 o ft. 260 ft. mom f
NC Well Contractor Certification Number P 'essing unit I
Greene Brothers Well & Pump f.�[f 3t*nD�iL'"� i 15.OUTER CASING for multi-cased wells OR LINER if a lic.b!e
WI��nC. Sed,On FROM TO DIAMETER THICKNESS MATERIAL
0 fL 64 ft. 61/4 in. SRD21
Company Name
MCM-173W 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. ft. in.
17. BE
Water Supply Well: FROM TO DIAMETER SLOT:SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. gentonite
Monitoring DRecovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
0 ft. 64 IL Clay
4.Date Well(s)Completed: 06/24/21 Well ID# 64 ft 305 ft Granite'
ft. ft.
5a.Well Location:
Mark Sundara
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
462 Lothlorien Rd Clyde 28721
Physical Address,City,and Zip ft. ft.
Haywood 8636-20-8419 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
j
35.502 N 82.922 W
Jai % mx�
A'O 06/24/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Con 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 Constriction Standards and that a
If this is a repair,fill out known well constniction information and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#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 I 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 100 (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 Injection 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
i
13a.Yield(gpm) 8 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 form within 30 days of
13b.Disinfection type: HTH Amount: 56 Tabs completion of well construction to the county health department of the county
where constructed.
E
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016