GW1-2022-07387_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft- 105 ft• 59am
4238 1os ft• a45 It' Sgp.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OIL if a licable
Greene Brothers Well &Pump, WT Inc. FRoM TO DIAMETER THICKNESS MATERIAL
0 ft, 64 ft. 61/4 in. SDR21
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
GJB-176W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. in.
List all applicable well construction permits(i.e.UIC,Count),,State, Variance,etc.)
rt. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public it. it. in•
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft, g, in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation
Non-Water Supply Well: p ft. 20 ft Bettor ire
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation ;,,;
19.SAND/GRAVEL PACK'if a `licable � >'�'=*�- -
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Stormwater Drainagett. ft.
Aquifer Test �
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Coolin Return) FROM TO DESCRIPTION(color,
color hardness,soiVrock type,grain size,etc.)Other(explain under#21 Remarks) 0 ft. 64 ft• Clay
07/06/22 64 [t• ass tt• Granite �-
4.Date Well(s)Completed: Well ID#
5a.Well Location: n
202-
Jeff Henson/Brandon&Stacey Rogers
Facility/Owner Name Facility lD#(ifapplicablc) ft• ft• u tl
139 Cedar View Ln Canton 28716
ft. ft. lflfCf''" nt+J �iuOG
ft. ft.
Physical Address,City,and Zip
Haywood
8644-23-0778 z1.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.Certification:
35.456 N -82.887 W I 07/06/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s)oZ Permanent or Temporary
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 ®No with 15A NCAC 02C.0100 or 15A NCAC 01C.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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 485 (ft-) 24a. For All Wells: Submit ithis form within 30 days of completion of well
For multiple wells list all depths if dii Brent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 (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) Method of test: 2 Hours 24c.For Water Supply&Injection 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: eg 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