GW1--03040_Well Construction - GW1_20230310

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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 0 ft- 400 ft. 114g
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING formulti cased wells OR LINER if a licable)
Greene Brothers Well &Pump,WT Inc. FROM TI DiAR'ETER THICKNESS MATERIAL
0 ft. 33 ft. 61/4, in. PVC
Company Name
W 1055-2022-0586 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' 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.
17.'SCREEN- -
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public % ft. in.
Geothermal(Heating/Cooling Supply) �XOResidential Water Supply(single) fL % 411.
IndustriaUCommercial DResidential Water Supply(shared)
18:GROUT`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
f-Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(d a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLUVG LOG attach additional sheets if necessa
BGeothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) 1
FROM TO DESCRIPTION color,hardness,soilfrock typ0.grain size,etc.)
0 ft. 33 ft. Clay
4.Date Well(s)Completed:02/01/23 Well ID# 33 ft. 625 ft, Granite
5a.Well Location: ft.. ft.
ft. ft bn..J iy.3 4',i ,.I •i
Yeni Escamilla - --
Facility/Owner Name Facility ID#(if applicable) ft. ft. fVlA t
853 Huckleberry Mountain Rd Hendersonville 28192 ft. ft.
Physical Address,City,and Zip ft. ft. -.t t
Henderson 9681-05-8960 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. rtiti lion
35.394 N -82.420 W
02/01/23
6.Is(are)the well(s)oPermanent or OTemporary Signature 6fCcrtified Well Contractor Date
By signing this form,I hereby certify that the rrell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EJNo wilt 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 under 421 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: 625 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 580 (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 27699-1636
13a.Yield(gpm) 114 Method of test: 2 hours 24c.For Water Suanly&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: 109 Tabs completion of well construction Ito the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016