GW1-2022-10811_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.Well Contractor Information: l
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Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418
p fL 305 it• 125ppm
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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
p ft. 60 ft. 61/4 I in, PVC
Company Name
SAS-236W 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.) 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 rIMunicipal/Public ft. ft. il.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Sentonite
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
L Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
I Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage
__ Experimental Technology D Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.
HGeothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) p ft• so ft• Clay
4.Date Well(s)Completed: 10/20/22 Well ID# so ft. 605 ft, Granite
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5a.Well Location:
Tana Baker
Facility/Owner Name Facility ID#(if applicable) ft. ft. D_
397 Tango Ln. Waynesville 28786
". n1Dti� 3v`U
Physical Address,City,and Zip ft. ft. �
Haywood 8646-42-4375 21.REMARKS "
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22. er cation: !
35.507 N -82.883 W
10/20/22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Cert' ed Well Conhactor Date
By signing this form,I hereby certify that the u+ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I)Yes or X No 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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Reso4rces,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 Injection 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1'25 Method of test: 2 Hours 24c.For Water Supply&Iniectioi Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 109 Tabs completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016