GW1-2023-02597_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only
1.Well Contractor Information:
i
Travis Greene .14 WATER ZONES.
Well Contractor Name FROM TO ft. DESCRIPTION
4238 fL
0 205 30-
205 ft* 345 fL —
NC Well Contractor Certification Number "15.OUTER CASING'for multi caseil'wells OR LINER'If a licable
Greene Brothers Well 8t Pump, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
p ft. 124 ft 1 6114 - in. PVC
Company Name .t t ..
W 122 1 r�01 1 1 1 7 1 16.INNER-CASING OR TUBING eothermal closed-loop) -
2.Well Construction Permit#• G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count)',State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:. 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [JMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) % ft.
lndustrial/Commercial [IResidential Water Supply(shared) 18:GROUT '
Irri ation FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. gentonite
Monitoring Recovery it. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
_ %19.SAND/GRAVEL PACK if applicable) '
Aquifer Storage and Recovery OSalinityBanier FROM TO MATERIAL EMPLACEDLEN-r METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
__ FROM TO DESCRIPTION(color,hardness,seil/rock e, rain size,eta
_
Geothermal Heating/Cooling Return) Other(explain under#21 Remarks)
p ft. 124 It- Clay
4.Date Well(s)Completed:03/21/23 Well ID# 124 ft- 405 ft" Granite
5a.Well Location: ft. ft.
Amayrani Garduza/James Alvarez ft. ft'
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
190 Hidden Knoll Dr. Hendersonville 28792 ft. ft.
ft. ft t ,_ ,,-w•r, ,1 r:, _ ,,. l,l±:i
Physical Address,City,and Zip
Henderson 9599-53-9663 =21.REMARKS - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.334 N -82.367 W
03/21/23
6.Is(are)the well(s)JMPermanent or Temporary 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: I Yes or [@No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 under#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: 405 (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@100) construction to the following:
10.Static water level below top of casing:60 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 (m.) 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) 4 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: 74 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