GW1--03159_Well Construction - GW1_20230505

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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. 2a5 ft i59m
rt. rt.
NC Well Contractor Certification Number '15.OUTER CASING for niulti�ased wells OR LINER rf a livable
Greene Brothers Well &Pump,WT Inc. FROM To DIAMETER THICIavEss MATERIAL
0 ft. n It. 6114 in, PVC
Company Name
DGS-016W , R 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counq•,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE TIHCKtTM MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft
Industrial/Commercial DResidential Water Supply(shared) .18.'GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AmouNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring ORccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology EJ Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ___ Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soilfrock typc in size,ctc.
0 ft. 77 ft. Clay
4.Date Well(s)Completed: 04/12/23 Well ID# 77 ft- 365 ft- Granite
5a.Well Location: ft. ft.
Don Eckler/Edward Enterprises LLC ft. ft. - •"
Facility/Owner Name Facility lD#(if applicable) ft. ft MAY ®, n
1015 Rabbit Skin Rd.Waynesville 28785 ft. tt
Physical Address,City,and Zip ft. ft. Ci'lir`d,La
Haywood 8710-20-1096 21•REMARxs -
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.Cc • ation:
35.607 N -82.996 W j
04/12/23
6.Is(are)the well(s)OPermanent or OTemporary Signature o ertified 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: E)Yes or XJNo with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
#'this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair tinder#21 remark section or on the back of this font.
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 I GW-I 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: 365 (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 1@I00) construction to the following'
10.Static water level below top of casing:240 (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 27699-1636
13a.Yield(gpm) 15 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: 67 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