GW1--04187_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14:wATERzoNEs - - ` - . ..
Well Contractor Name FROM TO DESCRIPTION
0 ft. 105 ft. zaps ,
2418
105 ft• 365 ft. i39,... I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable) '
Greene Brothers Well &Pump,WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 84 ft. 61/4 in' Steel
Company Name
aa' a -2 ``16.INNER CASINGOR TUBING(geothermal closed-loop)2.Well Construction Permit#: O 8 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire/1 construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well _17l:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*!Agricultural OMunicipal/Public ft. ft. in.
IN Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. fL in.
MI Industrial/Commercial DResidential Water Supply(shared)
I I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
VII Monitoring DROCOVCry ft. ft.
Injection Well:
ft. ft.
lit Aquifer Recharge Groundwater Remediation
'19.SAND/GRAVEL PACK(if applicable) "
•lAquifer Storage and Recovery I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*1 Aquifer Test 0StormwaterDrainage ft. ft.
1 Experimenta1 Technology IOISubsidence Control ft. ft.
III Geothermal(Closed Loop) IJTracer 20.DRILLING LOG(attach additional sheets if necessary).-._. ' .
111 Geothermal(Heating/Cooling Return) I�Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 84 ft. Clay
4.Date Well(s)Completed:06/07/23 Well ID# 84 ft. 365 ft. Granite
5a.Well Location: ft. ft.
David Huges ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft , n ,-.
Kendal Dr. Leicester 28748 ft. ft. ', b�r y y
ft. ft.
Physical Address,City,and Zip J li l n 6 `(i`3
Madison 8792-49-3898 21irREMARKS
County Pared Identification No.(PIN) IntZ cur-.1 J C it Pry,•!. r+fi Una
DW(''3'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi lion:
35.694 N -82.825 �,
l �_--- -� 06/07/23
IITemporary Signature o Certified Well Contractor Date
6.Is(are)the well(s)JPermanent or
By signing this form,I hereby certifiithat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: iJYes or ONo with 15A NCAC 02C.0100 or I5A 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: 385 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following: '
10.Static water level below top of casing: 50 (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 Injection 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&Injection 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: 65 tabs completion of well construction'to!the county health department of the county
where constructed.
I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22 2016