GW1-2023-02596_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418
p ft- 225 ft. sgpm
�
225 ft, 305 ft. zasam
NC Well Contractor Certification Number 1.15: CASING for multi cased wells)OR LINER if a Iicable
Greene Brothers Well &Pump, WT Inc. FROM To DIAMETER TrlicicxEss MATERIAL
p ft- 52 ft. 61/4 in- Steel
Company Name �+rttI
MCM-359W 16.INNER G9SING.ORTUSING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constuction permits(i.e.UIC,Coungt State,Variance,etc.) ft. tt. in•
3.Well Use(check well use): I ft. ft.
17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. i
Industrial/Commercial OResidential Water Supply(shared)
18:GROUT"
hri atipn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft- 20 ft. aentonite
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge FIGroundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if necessa"
__ FROM TO DESCRIPTION(color,hardness,soilfrock q grin size,etc.)
Geothermal(IIeating/Cooling Rearm) i_ Other(explain under#21 Remarks)
p ft. 52 ft, Clay
4.Date Well(s)Completed:02/22/23 Well ID# 52 ft. 325 ft. Granite
5a.Well Location: ft. ft. - ;. " -•
Gary Szyper ft. ft. nn
Facility/Owner Name Facility ID#(if applicable) ft. ft. n 1 r LLI 3
144 Fawn Trail Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 8662-69-3293
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. ertifica on:
35.419 N -82.806 W
02/22/23
6.1s(are)the well(s)OPermanent or 01remporary Signature o 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: nYes or E)No 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 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: ''IN (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 Service Center,Raleigh,NC 276994636
i
13a.Yield(gp ) 2 Hours 24c.For Water Supply&Iniection Wells: In addition to sending the form to
m 30 Method of test: g
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: sp tabs completion of well construction to 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