Loading...
HomeMy WebLinkAboutGW1-2022-08696_Well Construction - GW1_20220504 I' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I 1.Well Contractor Information: Robin Webb 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name ' p ft. 345 ft. 159vm 2418 ft. ft. 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 p ft- 25 ft' 61/4 , in. SDR21 Company Name J M Q-213 W 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. 17. Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural [Municipal/Public tt. ft. in4 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. m Industrial/Commercial DResidential Water Supply(shared) I8.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: p ft. 20 ft. gentonite Monitoring Recovery Injection Well: Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if a licable - Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test [Stormwater Drainage Experimental Technology Subsidence Control Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary) FROM TO DESCRIPTION color,hardness,soil/rock e, rain sim,etc.) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks 0 ft. 25 ft, Clay 4.Date Well(s)Completed:04/11/22 Well ID# 25 ft• 365 ft• Granite I. ft. ft. 5a.Well Location: Mark Galvin Facility/Owner Name Facility ID#(if applicable) ft. ft. 324 Upper Crabtree Rd. Clyde 28721 �— Physical Address,City,and Zip ft. ft. MAY 0 4 2022 Haywood 8639-24-0916 21•REMARKS County Parcel Identification No.(PIN) 1 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.C,orlf fiea n: 35.597 N -82.928 W S 04/11/22 6.Is(are)the well(s)oZ Permanent 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 02C.0200 Well Construction Standards and that a Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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: 365 (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: 1 (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 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) 15 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: 67 Tabs completion of well construction to the county health department of the county where constructed. i Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 i