GW1-2023-02552_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft- 165 ft. 159M
2418 ft. ft.
it
NC Well Contractor Certification Number .15.'OUTM CASING for multi cased wells OR LINER if a Ileable
Greene Brothers Well &Pump,WT Inc. P16.
TO DIMfETER' THICIINESS MATERIAL
ft. 82 ft' 61/4 in' PVC
Company Name ER.CASING OR TUBING eothermal closed-loo2.Well Construction Permit#:WEL2022-00047 TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
fL
3.Well Use(check well use):
17:SCREEN.
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural E)Municipal/Public ft.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. % rn•I
Industrial/Commercial Residential Water Supply(shared) t8.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 fL 9entonite
Monitoring Recovery ft. ft.
[Experimental
n Well: ft, ft.
er Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery ( Salinity Barrier FROM To MATERIAL EMPLACEII[ENT METHOD
r Test ElStonnwater Drainage ft. ft.
Technology Subsidence Control ft. ft.
ermal(Closed Loop) Tracer 20:DRILLING LOG(attach'additional sheets if necessaTO DESCRIMON color,hardn soiUreck c, in ' etc-
ermal(Heating/Cooling Return) rFlOther(explain under#21 Remarks) 0 ft. 82 ft. Clay
4.Date Well(s)Completed: 02/20/23 Well ID# 82 ft. 185 ft Granite
5a.Well Location: ft. ft. r `_� ,-_
John Hanson ft. ft. '� "�- =...JV.
Facility/Owner Name Facility ID#(if applicable) ft. ft. A fp R © 2.
469 Bob Barnwell Rd.Asheville 28803 ft. ft.
Physical Address,City,and Zip ft ft. r.r,e
`)} �1J0r..7
Buncombe 9665-99-1052 2LREM4RKS ;.
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:
35.511 N -82.464 W 02/20/23
t
6.Is(are)the well(s)oPermanent or OTemporary Signa ofCertr ed 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: I)Yes or EINo 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:
S.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: 185 (ft-) 24a. For All Weds: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
Ifnnter level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 9/4 (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,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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: 33 tabs completion of well constructions toi 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