GW1-2023-02599_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER:ZONES .
Well Contractor Name FROM TO DESCRIPTION
4238 NIA ft. N/A ft. wn
ft. ft.
NC Well Contractor Certification Number "'15.OUTER CASING for multi cased wells OR LINEf a li R if
Greene Brothers Well &Pump, WT Inc. FROM To DIMiETER THICKNESS MATERIAL
0 ft. PO ft- 61/4 ' in' I PVC
Company Name C �7 ;..
W I22 4 1 201 05532 16.INNER CASING OR TUBING geothermal closed-loop
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Ii.e.UIC,Counq,,State,Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaUPublic ft. ft. in'
I �
Geothermal(Heating/Cooling Supply) i)C Residential Water Supply(single) ft. ft. in.
Industrial/Commercial L Residential Water Supply(shared) 18.GROUT
h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. gentonite
Monitoring DRccovery ft. ft.
Injection Well:
ft. ft
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) I❑ITracer :20.-DRILLING LOG attach additional sheets if necessary)
eX FROM TO DESCRIPTION(color,hardness,soilfrock 4 in size,etc.
Geothermal(IIeating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 20 ft. Clay
4.Date Well(s)Completed:03/16/23 Well ID# 20 ft. 1,125 ft- Granite
5a.Well Location: ft. ft.
Kevin Phelan ft. ft. `_..
Facility/Owner Name Facility ID#(if applicable) ft. ft. 06
56 Evenstar Crest Hendersonville 28739 ft. ft.
Physical Address,City,and Zip
Henderson 9558-18-7623 21.REMARKS.
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:
35.316 N -82.514 W
03/16/23
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified ell 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: QYes or ONo with 15A NCAC 02C_0100 or 15A NCAC 01C.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 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: 1,125 (ft.
P ) 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'
060
10.Static water level below top of casing: 1, (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 Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 0 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: 204 tabs completion of well construction to the county health department of the county
where constructed.
II
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou rcei Revised 2-22-20I6