GW1-2023-02590_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 IL 185 ft. 2,,,
185 ft- 385 ft- t.rw. I38'F-4W29M
NC Well Contractor Certification Number 15.OUTER CASING for multi-e4sed wells)OR LINER if a livable)'.
Greene Brothers Well &Pump,WT Inc. FROM TO DIMIETER THICKNESS MATERIAL
0 ft- 99 ft. 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-IDD
2.Well Construction Permit#• SAS-218W FROM I To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couno%State.Variance,etc.) ft. I ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. [t. in.
Industrial/Commercial ORcsidential Water Supply(shared) 18.GROUT
Ir[I ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
L- Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I_ Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e.g min size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks 0 ft. 99 ft, Clay
4.Date Well(s)Completed:02/06/23 Well ID# ss ft. 505 ft.
Granite
5a.Well Location: ft. ft.
Kile Covell ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ` ` '="--•
101 Nightengale Place Waynesville 28786 ft. ft. APR 1 Q
Physical Address,City,and Zip ft. ft.l
REMARKS
Haywood 7695-62-5089 21•
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:
35.474 N -82.042 W `
��� 02/06/23
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or FXJNo 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 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 I 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: 505 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing: 100 (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 Injection 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) 6 Method of test: 2 hours 24c.For Water Supply&Iniectiim 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: s2 tabs completion of well construction Itol 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