GW1--03045_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene i;14.WATER ZONES.,
Well Contractor Name FROM TO DESCRIPTION
0 fL 285 ft. 129M li
4238
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS DATERIAL
0 ft. 70 ft. 1 61/4 in. PVC
Company Name J M Q-202 V V�/t� 16.INNER CASING OR TUBING( eothermat closed-loo')'
2.Well Construction Permit#' FROM TO DMAIETER THICKNESS 5ATERIAL
List all applicable well construction permits(i.e.UIC,Como,,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 THICFU�ESS MATERIAL
Agricultural [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fLR in
Industrial/Commercial DResidcntial Water Supply(shared) 18.GROUT '
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. 6entonite
Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(ifapplicable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage
Experimental Technology E)Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) ; FROM To DESCRIPTION color,hardness,sonfrock t e,grain size,etc.
( g/ g ) Other(explain under#21 Remarks) 0 ft. 70 ft. Clay
4.Date Well(s)Completed:01/09/23 Well ID# 70 ft. 305 ft. Granite _
5a.Well Location:
James& Robin Reeves ft. ft. MAR
1/i R � 0 2 ?1
Facility/Owner Name Facility ID#(if applicable) ft. ft. ri
285 Reeves Cove Rd. Clyde 28721 ft. ft.
Physical Address,City,and Zip
ft. ft.
Haywood 8639-54-3060 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:
35.594 N -82.918 w j /� 01/09/23
6.Is(are)the well(s)OPermanent or I❑ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: QYes or E)No with 15A NCAC 01C.0100 or 15ANCAC 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#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 GWA is needed. hidicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdderent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 60 (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 A (in.) 24b.For Injection 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) 12 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: 56 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