GW1-2021-02582_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Tad Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 65 ft. seaa
4364
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 It- 44 ft- 61/4 in. SRR21
Company Name
SAS-140W 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT,SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. gentonite
Monitoring Recovery
Injection Well:
tt ft.
Aquifer Recharge ®Groundwater Remedia]Re..ks)
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainageft, ft.
Experimental Technology Subsidence Controlft. ft.
Geothermal(Closed loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiltrocktype, rain size,etc.
Geothermal(Heating/Cooling Return Other(explain under#
0 ft. 44 ft. Clay
4.Date Well(s)Completed: 06/30/21 Well ID# 44 ft. 180 ft. Granite
5a.Well Location:
Jonathan Jones
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
200 Grassmere Ln Waynesville 28786 ft. rt.
Physical Address,City,and Zip ft. ft.
Haywood 7695-41-4822 21.REMARKS
County Parcel Identification No.(PIN) ceasing Uni,
n° WR Section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: E
35.473 N 83.053 Q d!
pJ ` ,^ 06/30/21
6.Is(are)the well(s)13Permanent or Temporary Signature ofCertified 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 ®No 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#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: 180 (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 1@100') construction to the following:
10.Static water level below top of casing: 60 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: hi 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) 12 Method of test: 2 Hours 24c.For Water Supply&IniecIti(in 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: ss Tabs completion of well construction to,the county health department of the county
where constructed.
i
Form G W-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016
I I