GW1-2022-08192_Well Construction - GW1_20220504

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb %44.;WATEWZONES,
FROM TO DESCRIPTION
Well Contractor Name
p ft. 185 ft. Bg97m
2418
ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt'-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM To DIAMETER TMCKNESs MATERIAI
p ft. 77 ft. 1 61/4 1 in. SDR21
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
SAS-175W
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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT -
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. PO ft. Bentonite
Monitoring Recovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation K 19.SAND/GRAVEL PAC if a licable
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)
Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
0 ft. 77 ft, Clay
4.Date Well(s)Completed: 03/24/22 Well ID# 77 ft. 205 ft. i
Granite,
5a.Well Location:
Matthew Torres
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Grapevine Cove Waynesville 28785 ft. rt. -
Physical Address,City,and Zip
Haywood 7790-82-5010 21.REMARKS `
County Parcel Identification No.(PIN) _
y is
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ',v: �` 1 t I 'im r-, ;>c L,ry►j
(if well field,one lat/long is sufficient) 2 ertif ation: ,
35.612 N -83.043 W
03/24/22
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 01C.0100 or 15.4 NCAC 02C.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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 50 (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.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of t1iis;form within 30 days of completion of well
12.Well construction method: construction to the following: j
(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 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: 36 tabs completion of well construction to the county health department of the county
where constructed.
is
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016