GW1-2021-02619_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Tad Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4364 0 rL 130 ft' 45g,,,,
ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER rHCKNESS MATERIAL
0 ft. 73 ft. 61/4 i in. SDR21
Company Name
MCM-226W 16.INNER CASING OR TUBING eofhermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conduction permits(i.e.VIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su I Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. R, in! l
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. inl
IndustriaVCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• 6entonite
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheetsif necessary)
FROM TO DESCRIPTION color,hardness soil/rock type,gmin size,etc.
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) 0 ft. 73
4.Date Well(s)Completed: 07/01/21 Well ID# 73 ft. 180 ft.
5a.Well Location: ft. ft.
Stephen Harris/Mike Crawford ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1703 Kims Cove Rd Canton 28716
Physical Address,City,and Zip
Haywood 8665-29-5407 21.REMARKS t
County Parcel Identification No.(PIN)
40�'�3• Rye .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification•
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35.503 N 82.821
� 07/01/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wel/(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 01C.0100 Well Construction Standards and that a
Ifthis 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 proNide 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 if derent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service iCenter,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 1/4
(in.) 24b.For Infection Wells: In addition tosending 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) 45 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: 33 Tabs completion of well construction too the county health department of the county
where constructed.
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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