GW1-2023-01567_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Green 14.WATER ZONES `. t
Well Contractor Name FROM TO DESCRIPTION
p It. 300 ft. ,g
4238 300 ft, 800 ft. 2gpm
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 THICKNESS MATERIAL
p ft. 34 ft. 6114 in, PVC
Company Name '16.'iNNER CASING OR TUBING !eothermal closed-loo
2.Well Construction Permit#:JCH-032W FROM TO DIA
METER 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.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural jDMunicipal/Public ft. ft. iu•
Geothermal(Heating(Cooling Supply) DResidential Water Supply(single) M ft. i
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL ENIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p fL 20 ft' Bentonite
Monitoring []Recovery ft. ft.
[Experimental
n Well:
ft. ft.
r Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) _
r Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test Stormwater Drainage
Technology OSubsidence Control ft. ft.
rmal(Closed Loop) I©ITracer .20.DRILLING LOG attach additional sheets if necessa__ FROM TO DESCRIPTION color,hardness,soil(mck C in size,etcrmal(Heating/Cooling Return) Other(explain under#21 Remarks)
a ft. 34 ft, Clay ;
4.Date Well(s)Completed:01/03/22 Well ID# 34 ft. 905 ft. Granite
5a.Well Location: ft. ft.
St. Aubin Treehouses LLC.
Facility/Owner Name Facility ID#(if applicable) ft. ft. F
654 Rich Cove Rd. Maggie Valley NC 28751 ft. ft. J
Physical Address,City,and Zip nt�...._. ''��• S.lr.�
Haywood 7687-21-4529 .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.Certification:
35.526 N -83.094 W �j ,�// 01/03/23
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 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 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: 905 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 240 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service11Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Infection 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 Service1Center,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: 165 Tabs completion of we11 construction Ito'the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou ies Revised 2-22-2016