GW1--03875_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 105 ft. ,aw
2418
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multt-,ased wells OR LINER if a livable
Greene Brothers Well 8t PUMP,WT Inc. FROM TO DGUIIETER THICKNESS MATERIAL
0 ft. 37 ft. 1 6114 1 in. PVC
Company Name
J MQ-285W 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit# FROM To DIAMETER TlucluvFss MATERIAL
List all applicable well construction permits Ci.e.UIC,County.State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICICAFSS MATERIAL
Agricultural E)Municipal/Publie ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 R. gentonite
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMEN-r METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology f3Subsidence 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,soiumek a rain sve eta)
0 ft. 1 37 ft. Clay
4.Date Well(s)Completed: 04/24/23 Well ID# 37 ft. 1,065 ft.
5a.Well Location:
Greenwood Estates LLC/Ken Mallette ft. ft. LJ
+ c
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �� ,rL:0 vt_
Cherokee Court Clyde 28721 f`• f` Il; ' 9 2
ft. ft.
Physical Address,City,and Zip w:rC41 f+Y,:SiCi ura
Haywood 8723-99-7549 21.REMARKS
UWWSOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. tific lion:
35.718 N -82.942 W r 04/24/23
6.Is(are)the well(s)OPermanent or OTemporary Signatu ofCerti6cd We ntractor Date
By signing this form,I hereby certify that the xvell(s)it-as(ivere)constructed in accordance
7.Is this a repair to an existing well: I)Yes or XX No with I5A 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 1he well owner.
repair under#21 remarks section or on the back of Otis jornr.
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: 1,065 00
p 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifauter 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 27699-1636
13a.Yield(gpm) 1/2 Method of test: 2 hours 24c.For Water Supply&Infection 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: 194 tabs completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016