GW1-2022-10815_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Robin Webb -14.WATER ZONES "- -.•
Well Contractor Name FROM TO DESCRIPTION
2418 0 ft. 720 ft. Igvm 4
ft. ft. I,
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. 32 ft 61/4 in. PVC
Company Name '
J M Q-279W 16.INNER CASING OR TUBING 'eothermal closed400
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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial IX Residential Water Supply(shared) 18.GROUT I
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. gentonite
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK if a' licable
j Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I3Stormwater Drainage
_ Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessa
Geothermal(Heating/Cooling Return) I_, Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
0 ft. 32 ft. Clay
4.Date Wells Completed: 10/28/22 Well ID# 32 ft. 1,005 ft. I
p Granite
5a.Well Location:
RFB Avalon
Facility/Owner Name Facility ID#(ifapplicable)
333 Tapestry Trail Waynesville 28785 ft. ft. DEC 0.9 2022
Physical Address,City,and Zip ft. ft.
t tr
21.REMARKS
Haywood 8618-31-8432
� o
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ;Zlification:
35.552 N -82.982 �, � ,, 10/28/22
6.Is(are)the well(s) iX Permanent or OTemporary Sign twe of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constnicted in accordance
7.Is this a repair to an existing well: QYes or E)No with 15.4 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 under#21 remarks section or on the back of this farm.
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
constriction,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: 1,005 (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: 740 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 1 Method of test: 2 hours 24c.For Water SunDIV&IniecItion Wells: In addition to sending the form to
the address(es) above, also subririt' one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 183 tabs completion of well construction to Ithe county health department of the county
where constructed.
• I
Forni GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016