GW1-2023-01568_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
4238 0 ft. 0 ft' WA DRY
ft. ft.
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
0 ft. 90, ft. 61/4 , in- PVC
Company Name i ,
^L+—O 1 c,n, 16.INNER CASING OR TUBING(geothermal closed4o6
D
2.Well Construction Permit#: GS V V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,etc.) % ft, in.
3.Well Use(check well use): ft. ft. j in. Y
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. i'
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single). ft ft ;�,,
Industrial/Commereial DResidential Water Supply(shared) 18.GROUT `
Irrigation FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Bentonite
-- Monitoring 'Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IOGroundwater Remediation -19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery I-. Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Storinwater Drainage ft. ft. j
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
0 ft. 90 ft. Clay
4.Date Well(s)Completed:01/16/23 Well ID# 90 ft. 825 fL Granite
5a.Well Location: ft. ft.
Don Eckler,Edward Enterprises LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft. F
1015 Rabbit Skin Rd.Waynesville 28785 ft,
Physical Address,City,and Zip ft. i,
Haywood 8710-20-1096 '2f.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) , 22.Certification•
35.607 -82.996 IY
01/16/23
6.Is(are)the well(s)�IX Permanent or [ITemporary 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: O Yes or ONo with 15A NCAC 02C_0106 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifdtis 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 tinder#21 remarks section or on the back of thisform. 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: 825 (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: 750 (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 27699-1636
13a.Yield(gpm) 0 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: 151 tabs completion of well construction t i 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
i