GW1-2022-10238_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb 14.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
2418 0 ft- 305 ft. 49om
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
0 ft. 61 ft. 61/4 in. PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2022-22795-9-11916
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.
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3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER': SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.i
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 ft. Hentonite
. Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 61 ft• Clay
4.Date Well(s)Completed:09/30/22 Well ID# B1 tt. 405 ft.
Granite
5a.Well Location: tt. ft.
Shawn Morgan "'
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1396 Parkway Dr. Maggie Valley 28751 Pr,+*Weog Uf*
Physical Address,City,and Zip
Jackson 7655-54-8956 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 2=Cer ' :
35.479 N -83.150 W h'
09/30/22
6.Is(are)the well(s)oPermanent or Temporary Signature a tfie ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)consirticted 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 tinder#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: 405 (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: 50 (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 thiis`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) 4 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: �a tabs completion of well construction to the county health department of the county
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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