GW1-2023-00433_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 p ft. 165 ft. 1o9vm l
165 ft* 280 ft. z9vm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ivells OR LINER if a Usable
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p ft. 86 ft. 61/4 1 1 in. PVC
Company Name
W EL2022-00292 16.INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e. UIC County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1171rrijzation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p tt. 20 it. Bentonite
I Monitoring IORecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
_
I Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i- Aquifer Test Stormwater Drainage ft. ft.
i Experimental Technology IOSubsidence Control
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 1
FROM TO DESCRIPTION(color,hardness,soilfrock type,grain siu etc.
0 ft. 86 ft- Clay `
4.Date Well(s)Completed: 11/10/22 sell ID# 86 rt' 305 ft, Granite
5a.Well Location: ,P is I=
Appalcian Wildlife/Randy Trantham rr. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft. l j
42 Stoney Creek Ln. Candler 28715 rr. ft. IO;O;:;U;�;I ;�;i,�;jVA•�, I,w:,
Physical Address,City,and Zip
Buncombe 8686-72-2479000 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 ertifieation
35.512 N -82.738 W '`
iedl'
I 11/10/22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor 1 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: niYes or X)No with 15A NCAC 02C.0100 or 15A NCAC 01C.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
I
9.Total well depth below land surface: 305 (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: 60 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 C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: 2 Hours 24c.For Water Supply&Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 5s tabs completion of well construction to the county health department of the county
where constructed. I. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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