GW1-2023-01566_Well Construction - GW1_20230209

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 ft. 225 ft. '009PM
2418
ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING for mul6-eased iiells TO LINER if a Gcable
Greene Brothers Well & Pump, WT Inc. FROM TO DLMtETER THICKNESS MATERIAL
p ft. 70 ft. 1 6114 in. PVC
Company Name M C M-355W 16.INNER CASING OR TUBING geothei•mal closed-loo' ' -. -.
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(cheekwell use): ft. ft. in.
17.Water Supply Well: FROSMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
hidustrial/Commercial IDResidential Water Supply(shared)
18.GROUT
Irritzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring ORccovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
•19.SAND/GRAVEL PACK(if applicable)_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (©3Stormwater Drainage
7Experimental Technology E3Subsidence Control % ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach,additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soil/rack type, in Sim,etc.
Geoth ermal(Heating/Cooling Return) Other(explain under#21 Remarks)
p ft. 70 ft- Clay
01/05/23 70 ft. 245 ft• Granite
4.Date Well(s)Completed: Well ID#
Sa.Well Location: ft.
r
Mark Trantham ft. ft. tl� J 9 3
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
a{'i�lbr y ::'r
1052 Coffee Branch Rd. Canton 28716 ft ft. •:,
Physical Address,City,and Zip ft. ft.
Haywood 8655-26-0081 :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) -.Cer )cation:
35.493 N -82.856 W 01/05/23
6.Is(are)the well(s)oPermanent or [3Temporary 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: E)Yes or EJNo 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: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 90 (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 A (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 276994636
13a.Yield(,-pm) 100 Method of test 2 Hours 24c.For Water Supply&Inie lion Welis: In addition to sending the form to
the address(es) above, also sutimit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 43 tabs completion of well construction)to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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