GW1--04192_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 ,
Travis Greene 14.WATER ZONES
-
Well Contractor Name FROM TO DESCRIPTION
0 ft. 105 ft- 12g,
4238 ft. ft.
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. 71 ft. 61/4 I 1 in. PVC
Company Name
2021-20780-9-11355 -16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in,
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring • DRccovery ft. ft.
Injection Well: it. ft.
Aquifer Recharge Ej Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
Aquifer Test ID Stormwater Drainage ft. ft.
Experimental Technology Ij Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
03 g/ g [Other(explain under#21 Remarks) 0 ft. 71 ft. Clay
4.Date Well(s)Completed:04/26/23 Well ID# 71 ft• 185 ft' Granite
5a.Well Location: ft. ft. _
Jason Boston ft. ft. :`L. ��. .-"'E
Facility/Owner Name Facility ID!'(if applicable) ft. ft. '�
52 Honey Locust Trail Whittier 28789 ft. ft. JUL 0 G 2n3
Physical Address,City,and Zip ft. ft. lnw�iifi,J^� Pt.-..,,.f, ,, EitI
Jackson 7603-35-2409
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.Certification:
35.418 N -83.354 W /l -
6.Is(are)the well(s) Permanent or Temporary Signa of Certified tractor Date
X
By signing this form,I hereby certiO that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with ISA NCAC 02C.0100 or 1SA 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells constmetion details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 185 (ft.) 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 topof casing:40
(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) 12 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: 33 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 Resources Revised 2-22-2016