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HomeMy WebLinkAboutGW1-2022-10811_Well Construction - GW1_20221209 i � WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ! 1.Well Contractor Information: l I I Robin Webb 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 2418 p fL 305 it• 125ppm � ! 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 a 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) I 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