GW1--03874_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Robin Webb 14.-WATERZONES
FROM TO DESCRIPTION
Well Contractor Name p ft. P05 ft.
sosP-
2418
ft. ft,
NC Well Contractor Certification Number -15 OUTER CASING for multi-cased rvells-OR LINER if a Hcable
Greene Brothers Well & Pump, WT Inc. FROM TO DiAl1fETER THICIQVESS MATERIAL
0 fL 33 fL 6114 I to PVC
Company Name �fl�
Y65INNER'CASINGORTUBING 'eotherinalclosed-loci '
GS-041tflI
�
2.Well Construction Permit#: V V V FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Counh,,State,Variance,etc.) ft. R. in.
3.Well Use(check well use): ft. ft. in.
REE
Water Supply Well: FROM TO, DUMETER, SLOT SIZE THICEICFSS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) M ft. in.
I- Industrial/Commercial XOResidential Water Supply(shared) IS.GROUT
1 Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft, Bentonite
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
i Aquifer Recharge Groundwater Remediation
_ 19:SAND/GRAVEL PACK Cif a �lipble
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMETTMETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control f4 ft.
Geothermal(Closed Loop) [3Tracer :•20 DRILI ING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soit/rock type,grain size,eta
p ft. 33 ft, Clay
4.Date Well(s)Completed:05/12/23 Well ID# 33 ft. 225 rt- Granite
5a.Well Location: ft.
Joe Zimmermann ft. ft.
Facility/Owner Name Facility ID#(if applicable) M ft.
61 Grapevine Cove Rd.Waynesville 28785 ft. R. tvo'er�tf�*fa�ra; ,�Ltr,
Physical Address,City,and Zip ft. ft.
Haywood 7790-81-1868 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.C is tion:
35.611 N -83.043 W,
05/12/23
6.Is(are)the well(s)OPermanent or OTemporary tgnature of Certified Well Contrac r 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: QYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.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 tinder#21 remarks section or on the back of thisform.
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: 225 UL) 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: 15 A) Division of Water Resources,Information Processing Unit,
If ureter 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 oflthis 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) 60 Method of test: 2 hours 24c.For Water Supply&Iniection Wells: In addition to sending the foam to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 40 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 Reso I s Revised 2 22 2016