GW1-2022-09291_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Travis Greene 14.WATER ZONES
Well Contractor Name SEp 2 8 ZGZ2
FROM TO DESCRIPTION
0 ft• 165 ft• so ypm
4238
rt. rt.
NC Well Contractor Certification Number NC DEQ/DWR
fal Office 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well & Pump vv I FROM TO DIAMETER THICKNESS MATERIAL
0 tt. 90 ft. 6 1/4 in. Steel
Company Name
SAS-172W 16.INNER CASING OR TUBING eothermat 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
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) OResidcntial Water Supply(single) tt. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 it. 13entonite
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK'if a licable ' <1
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soitfrocktype,grain size,etc.
0 ft- 90 ft. Clay ,
4.Date Well(s)Completed:08/04/22 Well ID# 90 ft. 185 ft.
Granite
5a.Well Location:
Cory King
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. OCI 0 U luzz
1581 Campbell Creek Rd. Maggie Valley 28751
Physical Address,City,and Zip ft. 3
Haywood 7676-62-4358 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.501 N -83.112 W
08/04/22
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor i 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 EJNo 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#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: 185 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resourcesl Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service JCenter,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: 33 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