GW1-2023-01565_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 125 ft.
4238
125 iL 245 ft• r.sypm � 24sa2.5'80m
NC Well Contractor Certification Number '15.OUTER CASING for multi ca"sed wells OR LINER if a licable)' .
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER TIHC[QVESS MATERIAL.
0 IL 54 ft- 61/4 in' PVC
Company Name
J MQ-174W 16.INNER CASING OR TUBiNG'( eothermal closed-loop)
-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) k. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FRSCREEN O DIAMETER SLOT SIZE THIci0rm MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. is
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 20 ft. eentonite
Monitoring [3Recovcry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test C_ Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soiitrack F"min sim,ctc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. Sq It. Clay �
4.Date Well(s)Completed:01/06/23 Well ID# 54 ft' 345 rt' Granite
ft. ft.
5a.Well Location:
James & Debra Mintz ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
252 Saddlebrook Ln. Clyde 28721 rt. ft.
Physical Address,City,and Zip ft. ft. In;Ci Fa E3;4�❑ ;ill^?�^yjs (rl
Haywood 8639-54-8705 2L-PEMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
35.595 N -82.917 W 01/06/23
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No with 15A NCAC 02C.0100 or 15A NCAC 01C.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: 345 (ft-) 24a. For All Wells: Submit this 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:
10.Static water level below top of casing:40 (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,
Center,Raleigh,NC 276994636
13a.Yield(gpm) 12 Method of test: 2 Hours 24c.For Water Supply&Iniection 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: 63 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