GW1-2022-03866_Well Construction - GW1_20220406

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. 200 ft. 1—
4238
200 ft• 500 ff .5apm
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 DL4METER THICKNESS MATERIAL
p ft. 152 ft- 1 61/4 in. SDR21
Company Name
16.INNERCASINGORTUBING eotherma]closed-loo
MCM-187W
2.Well Construction Permit#: FROM TO DL4ME'ER 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 ft. ft. iq•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial 13Rcsidcntial Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. sentonite
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 'licable j r s" °, " "7r1I
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) p ft. 60 ft, Clay
4.Date Well(s)Completed:03/02/22 Well ID# 60 ft. 705 ft.
Granite
5a.Well Location:
Seaira &Arnold Cabe ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
120 Choppy Dr. Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8645-96-9767 21.REMARKS -
I;" - ,
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:
35.492 N -82.863 W
03/02/22
6.Is(are)the well(s)19 Permanent or Temporary Signature of Certified Well ontractor 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: [3Yes or E]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 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: 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@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
Il.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) 1'5 Method of test: 2 Hours 24c.For Water Supply&Infection 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: 127 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016