GW1-2022-09284_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Robin Webb 14.WATER ZONES
Well Contractor Name SEp2022 FROM TO DESCRIPTION
L LL 2418 p ft- 545 ft. �
NC DE ft. ft.
NC Well Contractor Certification Number Q/DWR 15.OUTER CASING for cased wells OR LINER if a licable
Central Office FROM TO multi ETER DIAM THICKNESS MATERIAL
Greene Brothers Well & Pump, WT Inc.
0 ft. 134 1" 6 it,
in. PVC
Company Name
2022-22691-9-11804 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public rt. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt ft in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO fL Bentonite
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SANDIGRAVEL'PACK if a'`licable) Ads
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiUrock e, rain size,etc.
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks)
0 ft• 134 tt• Clay
4.Date Well(s)Completed: 08/19/22 Well ID# 134 ft• 565 ff Granite = ^�
5a.Well Location: <..-
Jacob Crotts rt. tt.
Facility/Owner Name Facility ID#(if applicable)
Down the Hill Rd. Sylva 28779
Physical Address,City,and Zip ft. ft.
Jackson 7672-97-6319 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.C anon:
r
35.404 N -83.096 W f
U � 08/19/22
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor h 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 ONo with 15A NCAC 02C.0100 or 15A 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#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-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: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 200 (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 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,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 20 Method of test: 2 Hours 24c.For Water Supply&Iniec`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: 103 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