GW1-2022-10813_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information:
Robin-Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPT,ION
2418 0 ff 305 ft 2gpm
ft. ft. f
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 DLAMETER THICKNESS MATERIAL
Company Name 0 ft- 60 ft- 61/4 i J in. PVC
JCH-016W 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROM
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. I ft. in,
Geothermal(Heating/Cooling Supply) i)(Residential Water Supply(single) it. ft. in.
Industriallcommercial IDResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
i Monitoring DRecovery
Injection Well:
ft. ft.
I Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
f Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
p ft. gp ft. Clay
4.Date Well(s)Completed: 11/03/22 Well ID# 60 fr 605 ft.
Granite
5a.Well Location: _M'S V ua
Dave Alessi
Facility/Owner Name Facility ID#(if applicable) ft. fr. DEC L�
266 Rockridge Dr. Maggie Valley 28751
Physical Address,City,and Zip
Haywood 7697-18-8077 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. rtificati n:
35.545 N -83.061 W
l� 11/03/22
6.Is(are)the wells) iX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(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 Slandards 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: 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@100) construction to the following:
10.Static water level below top of casing: 320 (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.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) 2 Method of test: 2 hours 24c.For Water Suably&Injection 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: 109 Tabs completion of well construction rto the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource s Revised 2-22-2016