GW1-2022-06564_Well Construction - GW1_20220708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 285 ft. s
2418 �°�
ft. ft. 1
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 DIAMETER THICKNESS MATERIAL
0 ft. 69 ft. 61/4 in. SDR21
Company Name
W E L2021-00385 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 THICIINESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
i
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in:
Industrial/Commercial Residential Water Supply(shared)
I8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt 20 rt Ilentonite
Monitoring Recovery
Injection Well:
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) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) f3 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rack type,grain size,etc.
0 ft. 69 ft, Clay
4.Date Wells Completed: 06/10/22 Well ID# 69 ft. 805 ft.
p Granite
5a.Well Location: ft. Ft. _ d
Ayalah Fisher
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
134 Pine Ridge Dr. Fairview 28730 rt. it. Pr0owung Unit
Physical Address,City,and Zip
fr. rt. pRi3C>�
Buncombe 9696-45-6727 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.Ce •on:
35.532 N -82.379 W
06/10/22
6.Is(are)the well(s)OZ Permanent or Temporary Signature dfCcrtified Well ontractor Date
By signing this form,I hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: ®Yes or ®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#11 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: 805 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii Brent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 445 (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 1/4 (in.) 246.For Injection 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) '25 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: ta7 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