GW1-2022-09293_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene RECEIVED 14.WATER ZONES
RIP
Well Contractor Name FROM TO DESC TION,
2418 SEP 2 8 2022 0 ft. 500 ft• rsapm
ft. ft.
NC Well Contractor Certification Number �ttr r� ® 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Brothers Well &Pump, vb rEIF—Q/DWR FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 80 ft. 61/4 1 in. SDR21
Company Name /��+ It
SAS-228 V V 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) in.
3.Well Use(check well use): ft. tt. in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt• 9entonie
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19...SAND/GRAVEL PACK`"ifa licable < `+ fig _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage tt. ft.
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 size,etc.
Geothermal (Heating/Cooling Return) Otber(explain under#21 Remarks) 0 tt. 60 tt• Clay j
4.Date Wells Completed:07/18/22 Well ID# 60 ft' 805 ft.
() P Granite r•.-�r�
5a.Well Location: ft. ft. ..:s .... . fi. l a..
Todd Frizelle ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Wake Robin Rd. Waynesville 28785
Physical Address,City,and Zip ft. ft.
Haywood 7699-53-6569 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:
35.588 N -83.054 W
5;j �,,�, , 07/18/22
Temporary Signature of Certified well Contractor; Date
6.Is(are)the well(s)OPermanent or
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 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: 805 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 560 (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 Iniection 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 Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service I.Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '75 Method of test: 2 Hours 24c.For Water Supply&Iniection 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: 1a�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