GW1-2022-07388_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
i
2418 o ft, 225 ft.
tt. rt.
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. 80 ft. 61/4 ! in. SDR21
Company Name
AKJ-456W 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. tt. in.
3.Well Use(check well use): ft. ft. in.
IN
ter Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural ®Municipal/Public tt. ft. m.
eothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial./Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 it. PO ft• Bentonite
Monitoring Recovery
ection Well:quifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK'if a licable quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test 13Stormwater Drainage ft• ft.
xperimental Technology Subsidence Controleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.eothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 50 ft. Clay �
4.Date Well(s)Completed: 07/13/22 Well ID# 50 ft 245 ft
Granite "
5a.Well Location: ft. tt.
Sherry King/Melinda Russell
Facility/OwncrName Facility ID#(ifapplicable) ft. ft. Ifl�%i4ri3aiD1 f>�
1277 Henson Cove Rd. Canton 28716
Physical Address,City,and Zip
Haywood 8655-55-7465 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.C Ica•on:
35.490 N -82.844 W
6;1- 07/13/22
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: ®Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Iniection 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) 60 Method of test: 2 Hours 24c.For Water SuDDIv&Iniec I tion 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: as Tabs completion of well construction jto 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