GW1-2022-07337_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 0 ft. 245 ft. ,ZBM
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a lica6le
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL s�0 ft. 66 ft. 6 1/4 in. BenlenileS;pg G 1
Company Name
WEL2021-00144 16.INNER CASING OR TUBING' eotherma]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): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation �r
19.SAND/GRAVEL PACK if a 'licable - ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks)J 0 ft. 86 ft. Clay
4.Date Well(s)Completed:07/05/22 Well ID# 86 tt. 285 ft.
Granite
5a.Well Location:
Sam Koerber/KOR Construction,LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft. E
39 Bent Creek Preserve Rd.Asheville 28806 ft. ft. AUG 022
Physical Address,City,and Zip ft. ft. 1ilfCfPrialQ4Dn Pr +
Buncombe 9625-29-5147 21.REMARKS DIVOIROG
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. tea n
35.507 N -82.622 W
07/05/22
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: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.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-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: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ different(example-3@200'and 2@100D 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
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:
(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) 12 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: 47 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