GW1--03158_Well Construction - GW1_20230505

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 o ft- 185 fl• ,�
185 ft. 305 ft.
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 MATERIAL
0 ft. 33 It' 61/4 4 in. PVC
Company Name .
DGS-037W 16.dNNER CASING OR TUBING eothermal closed-loop) ',
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,{variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DLIAETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
11T1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- PO ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test 01 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRULLING'LOG(attach additional sheets if necessa' )'
FROM
DESCRIPTION color,hardness,soittrock 4 in sizr,eta
Geothermal(Heating/Cooling Return) i.
) . Other(explain under#21 Remarks)
0 ft. 33 ft, Clay
4.Date Well(s)Completed:03/24/23 Well ID# 33 ft. 405 It. Granite
5a.Well Location: ft. ft.
Jon Holcomb/Eagles Nest Mtn.Const.Inc. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY
2490 Cove Creek Rd.Waynesville 28785 ft. ft.
Physical Address,City,and Zip ft. ft. ,,i=`
Y Y. P Ot_3?tea
Haywood 8700-24-3425 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'
35.618 N -83.032 W
03/24/23
6.Is(are)the well(s)oPermanent or EITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the isr/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or X]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constriction 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:
S.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: 405 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:Artesian (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 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) 4 Method of test: 2 Hours 24c.For Water Supply&Iniection Wells: In addition to sending the four to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 74 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