GW1-2023-01570_Well Construction - GW1_20230209

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft- 205 ft. namn
2418
ft. rt.
NC Well Contractor Certification Number 15.OUTER'CASING for multi-cased wells OR LINE ifR a ticable
Greene Brothers Well & Pump, WT Inc. FROM To DIAMETER Tml Ess MATERIAL
0 rt. 29 rt 51/4 r in. steel
Company Name
M C M-35 W 16.INNER CASING OR TUBING eotherinal closed-loop)
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(checkwell use): ft. ft. in.
17.SCREEN "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ni Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial X Residential Water Supply(shared) GROUT
Irrijzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentoriite
_ Monitoring 13Recovcry ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional sheets if necessary)'
El
Geothermal(Heating/Cooling Return) (— Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rocke m sire etc.)
0 ft. 29 ft, Clay
4.Date Well(s)Completed: 12/30/22 Well ID# 29 ft 225 ft, Granite
5a.Well Location: ft. ft.
David Moehlenkamp ft. ft. �" `��°i�� s V F;m;
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEB
4q n
202 Crawford Creek Rd. Canton 28716 ft. ft.
Physical Address,Ci and Zip ft. ft. v
Y tY. P M Q/30Lz
Haywood 8662-33-6474 21.REMARKS
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��
(if well field,one fat/long is sufficient) 22. eCT rfit-L'on J
35.393 N -82.850 W
v 12/30/22
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: QIYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#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: 225 (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@I001 construction to the following•
10.Static water level below top of casing: 15 (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 Servic6 Center,Raleigh,NC 276994636
13a.Yield(gpm) 7 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: 40 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