GW1--03156_Well Construction - GW1_20230505

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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 0 fL 245 fL 3cm
245 fL 425 ft. rgpm
NC Well Contractor Certification Number "15.OUTER CASING for multi-cased'wells OR LINER d a"licable'
Greene Brothers Well &Pump, WT Inc. mom TO DIAMETER THICKNESS MATERIAL
0 ft- 1 112 ft- 61/4 in PVC
Company Name
W�22120106662 16:INNER CASING ORTUBING` eotherinalclosed-loo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Count)%State,Variance,etc.) ft. IL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in;
II IndustriallCommercial DResidential Water Supply(shared) IS:GROUT
17hrriization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 fL eentonite
Monitoring [3Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery I_ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
:')Experimental Technology ©ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if mcessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sonfrock typc,gmin size,etc.)
0 ft. 112 ft, Clay
4.Date Well(s)Completed:04/13/23 Well ID# 112 fL 505 ft,
Granite
5a.Well Location: ft. ft. . . �; ��_
Garner Construction/Skydance LLC ft. ft. —1 ' `"
Facility/Owner Name Facility ID#(if applicable) ft. fL MAY 0e
ZUZJ
Lot 2 Skydance Trail Horse Shoe 28739 ft. ft.
Physical Address,City,and Zip ft. ft. j,�}ems ry�l7 j
Henderson 9549-41-5986 2L 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:
35.323 N -82.540 W
A- 0 04/13/23
6.Is(are)the well(s)OPermanent or [:]Temporary Signature of Certified Wet.Contractor Date
By signing this form,1 hereby certify that the i ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 dris 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 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-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,
If water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Infection 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) 4 Method of test: 2 hours 24c.For Water SuDDIv&Injection 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: sE 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