_Well Construction - GW1_20230310 (64)

to
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb ,14:wATERZONES,
Well Contractor Name FROM TO DESCRIPTION
p ft. 185 It. �. �
2418 ft. ft. I j
NC Well Contractor Certification Number OUTER CASING for multi�ased wells OR LINER.if a licable
Greene Brothers Well &Pump, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
p ft. 84 ft. 6114 in.
Steel
Company Name 1.
WEL2O19-00256 16;INNER CASING OR TUBING eothermal closed-Ido -
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counq,,State,Variance,etc.) ft. I in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: '17.SCREEN'.r.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ;n.
RIndustrial/Commercial Residential Water Supply(shared) is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft- 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if a licable
( Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. it..
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20 DRILLING.LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return FROM TO DESCRIPTION(color,hardness,soiVrack c rain size,etc.
(H g/ g ) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 12/12/22 Well ID# ft. ft.
5a.Well Location: ft. ft.
Ashley Medford
Facility/Owner Name Facility E)#(if applicable)
ft. ft. MAR y 0 2023
11 Davis Chapel Rd. Candler 28715 ft. ft.
1t„
Physical Address,City,and Zip ft. ft. J y
Buncombe 8684-69-1963000 21•REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.CAP tition:
35.478 N -82.472 W
L( 1\e�6 12/12/22
6.Is(are)the well(s)OPermanent or OTemporary Signatide 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 QNo 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 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: 205 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 15 (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 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) 30 Method of test: 2 Hours 24c.For Water Supply&Iniection Wells: hi 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: ss 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