GW1-2022-09290_Well Construction - GW1_20221006

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
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Travis Greene 14.WATER ZONES
Well Contractor Name r� Q FROM TO DESCRIPTION
4238
S E f" 2 f3 2022 0 ft. 425 ft. mom
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425 ft• 440 ft. so ePm
NC Well Contractor Certification Number NC DEQ/DWR 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. Central Office FROM To DIAMETER THICKNESS MATERIAL
0 It. 147 ft- 61/4 ! to Steel
Company Name
SAS-225W 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 Su 1 Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic ft. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT i
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. eentonite
Monitoring DRecovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
19.rSAND/GRAVEL
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft. 147 ft. Clay I
rt. rt.
4.Date Well 07/29/22 s)Completed: Well ID# 147 aa5 Granite
5a.Well Location:
Joe Kincart
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. O
Woods Rd. Waynesville 28785
Physical Address,City,and Zip ft. ft.
Haywood 7688-87-3573 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
N W ,1441 y 146L � I 07/29/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor I Date
By signing this form,I hereby certiifv 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 NC.4C 02C.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#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: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijJerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 100 (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 Resources1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50+ 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: 61 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