GW1-2023-00453_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
I f
4238 o rt. 330' ft. ao¢vm
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells TO LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. g2 ft. 61/4 in. PVC
Company Name
SAS-219 W 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: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft. in,
I Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
I_ h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. eentonite
Monitoring _ ([]Recovery
Injection Well:
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)_
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage
Experimental Technology []Subsidence Control
I Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness soil/rock t• F grain size,etc.)Other(explain under#21 Remarks) o ft. 92 it. Clay
4.Date Well(s)Completed: 12/02/22 Well ID# 92 ft. 365 ft.
Granite
5a.Well Location: ft. ft. v --�7)
Ethan Smith
Facility/Owner Name Facility ID#(if applicable) ft. ft. J I 0 9 LU•
421 Parrish Farm Rd. Waynesville 28786 ft. ft. . �r -n;r ibis
Physical Address,City,and Zip ft. ft.
Haywood 8614-33-0255 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:
35.452 N -82.986 W 12/02/22
6.Is(are)the well(s) X Permanent or []Temporary 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: []Yes or )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 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: 365 (ft.) 24a. For All Wells: Submit this+form within 30 days of completion of well
For multiple wells list all depths ifdier•ent(example-3@200'and 2@100D construction to the following: j
10.Static water level below top of casing: 220 (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 Iniection 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: t
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceiCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: 2 hours 24c.For Water SuDDIy&Iniection Wells: In addition to sending the form to
the address(es) above, also subirrit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: s7 Tabs completion of well construction rto the county health department of the county
where constructed.
it
Forni GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016