GW1-2023-01429_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name p
p ft. 85 ft. 3oywn 1
2418
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;veils OR LINER if a licable) '
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL.
p ft• 42 fL 61/4 in' PVC
Company Name
WEL.2�2�-��215 16:INNER CASING ORTUBING eothermalclosed=loo -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS INATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. ! in•
1 Well: °17.SCREEN
Water Supply Y FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural OMunicipal/Public ft. fL in.'
Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft. in•j j
I Industrial/Cornmercial OResidential Water Supply(shared) '18.GROUT I
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[— mental
ter Supply Well: 0 ft. 20 ft. Bentonite
oringRccovcry
n Well:
er Recharge Groundwater Remediation
19.,SAND/GRAVEL PACK if applicable)
r Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test I©IStormwater Drainage ft. ft.
Technology Subsidence Control
ermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrock e, rain sire,etc.ermal(Heating/Cooling Return) MOther(explain under#21 Remarks) 0 ft, 42 ft. Gay
4.Date Well 11/28/22 s)Completed: Well lD# 42 ft. 85 ft. Granitei (�• 9".''�.—_ a� �';�'9 ice,
V :I
5a.Well Location:
Eric Usher/Rare Earth Bldrs(Mark Bondurant) ft. ft. F L 1 B I 023
Facility/Owner Name Facility ID#(if applicable) ft. ft. L !
4 Red Cypress Ln. Weaverville 28787 ft, ft. "' DANUBOG
Physical Address,City,and Zip ft. ft.
Buncombe ��S3)Ny39 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certifi a'on:
35.711 N -82.533 �, 1
11/28/22
6.Is(are)the well(s)OPermanent or OTemporary 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 E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out/mown well construction information and explain the nature ofthe copy ofthis record has been provided to the ivell 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 85 (ft-) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: I,
10.Static water level below top of casing: N/A Artesian 00 Division of Water Resources,Information Processing Unit,
Ifuater 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 ofthis 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 276994636
13a.Yield(gpm) 30 Method of test: 2 Hours 24c.For Water Suaaly&Iniecion 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: to 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 Resoul es Revised 2-22-2016