GW1-2023-00457_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 p ft, 80 ft.
I.- `
60 ft, 485 ft. seam I laesaoai¢pm
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 THICKNFss MATERIAL
p ft. 41 ft. 6114 in, PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: MCM-363W 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.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. i�t•
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial iX Residential Water Supply(shared)
1S.GROUT 11 +
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonlie
.. Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
Experimental Technology D Subsidence Control
RGeothermal
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessar)
(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soivrock type,grain size,etc.
0 ft. 41 ft. Clay
4.Date Wells Com leted: 11/11/22 Well ID# 41 if 705 if Granite °
5a.Well Location:
Matt Bare ft. ft. JAN 0 9 2023
Facility/Owner Name Facility 1D# if applicable)
2504 Crabtree Mountain Rd. Clyde 28721
Physical Address,City,and Zip ft. ft.
Haywood 8659-11-3161 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:
35.586 N -82.863 W
11/11/22
6.Is(are)the wells)IX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certifj,that the uvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well• OYes or E)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 foru:.
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: 705 (ft•) 24a. For All Wells: Submit tliis`form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100D construction to the following. 1 r
10.Static water level below top of casing: 300 (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:
(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) 3 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: 127 Tabs completion of well construction)to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016