GW1-2022-05809_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contragtor Information:
Robin Webb 14,WATER ZONES o
Well Contractor Name FROM TO DESCRIPTION
2418
p ft. 285 ft. 41',
rt. rt.
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 THICKNESS MATERIAL
p ft. 75 ft. 61/4 i 1°• Steel
Company Name
SAS-144W 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.) 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. in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial 18
Residential Water Supply(shared) .GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite
Monitoring Recovery ft. ft.
Injection Well:
ft. tt.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable).
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 sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) p ft. 75 ft. Clay
4.Date Wells Completed: 05/03/22 Well ID# 75 tt 305 ft.
p Granite
5a.Well Location: tt. ft. K ,; ,.
@.-,.
Thomas Holshue ft. ft. 6-9 2
Facility/Owner Name Facility ID#(if applicable)
ft. ft. I inn
Lot 45 Jonathan Trail/Soco Falls Maggie Valley 28751 ft. ft. I0(00faia' IInOG "
Physical Address,City,and Zip ft. ft.
Haywood 7666-65-1211 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. t lion:
35.506 N -83.147 M
05/03/22
6.Is(are)the well(s)OPermanent or 13Temporary 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: [3Yes or JMNo 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 ofthe 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 I 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: 305 (ft-) 24a. For All Wells: Submit this'.form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater 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
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: G
(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
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13a.Yield(gpm) 45 Method of test: 2 Hours 24c.For Water Suanly&Infection Wells: In addition to sending the form to
the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 56Tabs completion of well construction tolthe 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