GW1-2023-00452_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 280 ft* 608Pm I
ft. ft. l
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. 60 ft- 61/4 In PVC
Company Name
SAS-229W 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.) in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]MunicipaVPublic ft. ft. in,
Geothennal(Heating/Cooling Supply) 'JE Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring Recovery ft. ft.
InWe
RcAqinellh:a rge ft. ft.
Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
f Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type. rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 60 ft- Clay
4.Date Well(s)Completed: 12/07/22 Well ID# 60 ft. 325 ,ft• Granite
5a.Well Location:
Plott Creek Dev.LLC/Benchmark Builders ft. ft. [ ' s•G n at 1=
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1855 Running Deer Trail Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft. ;Gi. ?:, ;�,i.• :y?.;; ;�l! :l
Haywood 7685-67-7030 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.Certification:
35.490 N -83.066 W I.
12/07/22
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Certified Well Contractor; Date
By signing this form,I hereby certify'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 I 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: 3J05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
I
10.Static water level below top of casing:20 (ft.) Division of Water Rml ces,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61A (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.) i
Division of Water Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service:Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test: 2 Hours 24c.For Water Supply&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: 67 Tabs completion of well construction ItoI the county health department of the county
where constructed.
I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water ResourcI s Revised 2-22-2016