GW1--03157_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene Yi;14.WATER'ZONEs
Well Contractor Name FROM TO DESCRIPTION
4238 p ft- 60 ft. s p
ft. ft. h
NC Well Contractor Certification Number "15 OUTER'CASING for:_multi cased wells OR LINER da licable
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER TI➢CKNESS MATERIAL
p ft- 26 fi- 61141 � in. PVC
Company Name ,
W�22 20 03796 16::INNER CASING OR 1 URING eotherinal clmed400
2.Well Construction Permit# FROM TO DIMIETER THICKNESS MATERIAL
List all applicable well construction permits li.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(checkwell use): ft. ft. in.
Water Supply Well: `17.SCREEN:.;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunieipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite
F Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology EJ Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach`additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.
p ft. 26 ft- Clay
4.Date Well(s)Completed:03/22/23 Weil ID# 26 ft. 165 ft, Granite
5a.Well Location: ft. ft.
Colby Wells ft. ft. _ •�-e` �
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 1
128 Antebellum Way Hendersonville 28792 ft. ft.
Physical Address,City,and Zip ft. ft. C!
Henderson 9691-63-7729 '.2LREMARKS'•,-"
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:
35.391 N -82.366 W
1J1 z" �, ,. 03/22/23
6.Is(are)the well(s)'X Permanent or [ITemporary 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: DYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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:
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: 165 (ft-) 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@100D construction to the following:
10.Static water level below top of casing:60 (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(,-pm) 9 Method of test: 2 hours 24c.For Water Supply&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: 29 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resoure i s Revised 2-22-2016