GW1--04201_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES -.
Well Contractor Name FROM TO DESCRIPTION
0 ft. 100 fL iomp„ I 1
4238 -
100 ft• 200 ft• logo. l
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
Company Name 0 1L 68 f• 61/4 in. PVC
NC H-044W 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: l�fl V II 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. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
in.
Geothermal(Heating/Cooling Supply) ®i Residential Water Supply(single) ft. fL
Industrial/Commercial Residential Water Supply(shared) 18:GROUT ."
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Bentonite
Monitoring Recovery ft. ft.Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__Aquifer TestIStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DI Tracer 20.DRILLING LOG(attach additional sheets if necessary)- -
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
•
0 ft. 68 ft. Clay
4.Date Well(s)Completed: 05/25/23 Well ID# 68 ft. 225 ft. Granite
5a.Well Location: ft. ft.
Brandon Green ft. ft. % F a $f y _")
Facility/Owner Name Facility ID#(if applicable) ft. ft
11 Corbin Ln.Waynseville 28786 ft. ft. JUL' 0 6 202n
Physical Address,City,and Zip ft. ft. itIk it:•%I1C,i1 f m .Cr 44:74 UJn-
Haywood 7694-14-0682 21.REMARKS - 1.P.=4t:43• .., , _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22 rtification:
35.453 N -83.060 W ti_ 2- -k—_-- 05/25/23
6.Is(are)the well(s)IPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or- XONo with ISA NCAC 02C.0100 or ISA 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#11 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 1/4 (in.) 24b.For Iniection 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) 20 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: 40 tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016