GW1--03877_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
p f4 P85 ft. �Sgpm
2418
ft. ft.
i
NC Well Contractor Certification Number 15;OUTER CASING for multi cased wells OR LINER if applicable)
Greene Brothers Well &Pump, WT Inc. FROM To DIAMETER THICKNESS MATERIAL
p ft. 24 ft. 6114 in.
PVC
Company Name ,
J�Q-229 d Ytt, 16:INNER CASING OR TUBING(geothermal closed-loo `
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 S t Well: 17.'SCREEN
u
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipaVPublic tt ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft- M
IndustriallCommercial IOResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring 'Recovery % ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery L Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology III Subsidence Control ft. ft.
Geothermal(Closed Loop) bTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) { Other(explain under#21 Remarks)] FROM TO DESCRIPTION color,hardness.soi1frock type,grain size,etc.
p ft. 24 ft- Clay
4.Date Weil(s)Completed: 05/16/23 Well ID# 24 ft. 305 ft.
Grande
5a.Well Location: ft. ft. y f-• -e• r.,
Laura Calenberg ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft• fL JUN 2023
1190 Lentini Dr. Waynesville 28785 ft. ft.
?�anO
Physical Address,City,and Zip ft. ft.
Haywood 7698-50-7137 '-21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latlong is sufficient) 22.Cc a n•
35.551 N -83.050 W
05/16/23
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contrache Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XONo with 15.4 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 form.
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: 305 (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 2@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 27699-1636
13a.Yield(gpm) 15 Method of test: 2 hours 24c.For Water SuDDIv&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: 5s 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 Resour I ces Revised 2 22-2016