GW1-2022-03116_Well Construction - GW1_20220303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 p ft. 405 ft- sgpm
405 ft. 845 ft. sgbm h
NC Well Contractor Certification Number 15.OUTER CASING for mu1N cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p ft. 77 ft. 61/4 in. SDR21
'
2020-16350-9-10815 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.) tt. ft, in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared)PP yhd( ) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Ilentonite
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.'SAND7GRAVEI;PACKI ifa 'licable r"'
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUrock type, rain size etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks o ft. 77 ft. clay
4.Date Well(s)Completed: 02/08/22 Well ID# 77 ft• 1,105 ft' Granite
5a.Well Location:
John & Pam Demartino
Facility/Owner Name Facility ID#(if applicable) ft. it.
11-' =n
186 Stemwinder Rd. Sylva 28779
Physical Address,City,and Zip ft. ft. •-
Jackson 7672-92-0415 21.REMARKS 1-- 1 _.,
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.Cc ea on:
35.383 N -83.094 W 02/08/22
6.Is(are)the well(s) Permanent or Temporary Signature ofCcrtified 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 Jallo 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.
filled'2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1,105 (ft-)
P 24a. For All Wells: Submit thisi form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing:420 (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 A (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) 3 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: 20o 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