GW1-2022-03055_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
p ft. 245 ft. 29M
4238 I 245 ft. 565 ft. .ssw.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased iyclls OR LINER if a US,,, e
Greene Brothers Well & Pump, WT Inc. FROM TO DIAi11ETER THICKNESS MATERIAL
p ft. 1 21 ft. 1 61/4 in. SDR21
Company Name �e�
M C M-289 V V 16.INNER CASING OR TUBING( eolhermal closed400
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): it. rt. in,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public (t. [t. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT Fr
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. eentonite
Monitoring Recovery_
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVELTACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionaVshects if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 21 ft. Clay
4.Date Well(s)Completed:02/09/22 Well ID# 21 ft. 705 tt. Granite B
5a.Well Location:
ft. ft.
Farmworks LLC It e• MAR
Facility/Owner Name Facility ID#(if applicable)
•J�
245 River Farm Ln Canton 28716 a• It. 1�� (y�Fc...,, 1
Physical Address,City,and Zip ft. ft. t.
Haywood 8644-17-1382 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.Certification:
34.416 -82.928 N
02/09/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified 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 orNo with 1 SA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this font.
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-I 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: 705 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below to of casing:60
p g: (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
.Well construction method:
Rotary above, also submit one copy of this form within 30 days of completion of well
(i.. construction to the following:e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,ULerground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce Enfter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2.5 Method of test: 2 Hours 24c.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit Zone copy of this form within 30 days of
136.Disinfection type: HTH Amount: 127 Tabs completion of well construction to the county health department of the county
where constructed.
Foml GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016