GW1-2021-02075_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb E 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 185 ft. ioew�
1111
2418 �Ut- O d 202+1 185 ft' 305 it' Sapm 390'to 385'tagpm
NC Well Contractor Certification Number
Greene Brothers Well & Pump, WT Inc.�11fOII1',3t1on processlrl UTER CASING for mull cased wells I T LINER S a licable
FROM TO DIAMETER THICKNESS MATERIAL
��SBvt;0I1 0 ft. 1 29 ft. 1 61/4 1 in. Steel
Company Name
2020-16421-9-10814 16.INNER CASING OR TUBING eothermal 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.
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3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. ; , !
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring Recovery
Injection Well:
tt. 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 ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soii/rock type,gnin size,etc.
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks)
0 ft. 29 ft, Clay '
4.Date Weil(s)Completed:06/03/21 Well ID# 29 ft 405 ft Granite
5a.Well Location:
Steven Derderian
Facility/Owner Name Facility ID#(if applicable) ft. ft.
83A Reservation Rd. Maggie Valley 28751 ft. ft.
Physical Address,City,and Zip ft. ft.
Jackson 7655-81-8105 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. tiftea' n:
35.472 N 83.174 W
06/03/21
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)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 out known well construction information and explain the nature ofthe copy ofthis 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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: 15 (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.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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: 74 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