GW1--03876_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14,WATERZONES
FROM TO I DESCRIPTION
Well Contractor Name
4238 0 fL 240 ft. syPm
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cif'sed wells OR LINER if a Rcable
Greene Brothers Well & Pump,WT Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft 111 ft 61/4 in• Steel
Company Name
16:INNER CASING OR TUBING 'eothermal closed-loo
2.Well Construction Permit#: SAS-246W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell 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
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
__lndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
H ation FROM TO' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 % eentonite
Monitoring [311ccovery tt. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [D Stormwater Drainage tt• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 1ITracer .20.DRILLING LOG attach additional sheets if necessary)
_ __ FROM TO DESCRIPTION color,hardness,son track e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. ill It- Clay
4.Date Well(s)Completed:05/19/23 Wen ID# ill ft- 285 ft, Granite
5a.Well Location: ft. ft. R,
George Young ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. t 3
39 Gristmill Dr.Waynesville 28786 ft ft. kbbx,Wcn p fat, ,� 1
Physical Address,City,and Zip ft. ft.
Haywood 7684-73-4956 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification:
35.451 N -83.072 W
JL � �, _ _ _ 05/17/23
6.1s(are)the well(s)oPermanent or Temporary 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: QYes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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:under#21 remarks section or on the back of this fonn.
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: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 1@100 construction to the following.
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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(glim) 5 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: 51 tabs completion of well construction t6 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