GW1-2023-02600_Well Construction - GW1_20230410

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Travis Greene 14,wATERZONES -
We1lContractor Name FROM TO DESCRIPTION
p ft- 120 ft rsaam
4238
ft. ft. ,
NC Well Contractor Certification Number `15.OUTER CASING for mull-cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIMIETER THICKNESS DATERIAL
p f1. 8q ft 61/4 t° PVC
Company Name
W I2212O 106662 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER s I THICKNESS MATERIAL
List all applicable uwll construction permits(i.e.I11C,Countyt State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '.17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKINESS MATERIAL
:)Agricultural DMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fL tn.
Industrial/Commercial IDResidential Water Supply(shared) 18.'GROUT .
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
i JAquifer Recharge Groundwater Remediation
19.'SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
BGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM I TO DESCRIPTION rotor,hardarss,sail(rock type,grain sire,etc.)
p ft. 84 ft. Clay
4.Date Wells Completed:03/27/23 Well ID# 84 ft. soy ft. Granite
ft. ft
5a.Well Location:
Skydance LLC/John&Alexa Clayton ft. ft. APR 1 n
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Skydance Trail Horse Shoe 28739 ft. ft.
Physical Address,City,and Zip ft. ft. J
Henderson 9549-41-5986 .21.REMARKS
County Parcel Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35.324 N -82.539 W
03/27/23
6.Is(are)the well(s)OPermanent or OTemporary 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 QNo with I5A NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If[his 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: 505 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (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
13a.Yield(gpm) 1'5 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: 92 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
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