GW1--04345_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 1
1.Well Contractor Information:
Travis Greene 14.WATER ZONES "
We1lContractor Name FROM TO DESCRIPTION
0 ft- 200 ft- to yp
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. 90 ft61/4 in. PVC
Company Name
WP 19-095 t-16.INNER CASING OR TUBING(geothermal'closed=loop) - _ _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural DMunicipal/Public ft. ft. in.
III Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
*ilndustrial/Commercial DResidential Water Supply(shared) 18.GROUT - -
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft- Bentonite
**Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
•1Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
all Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test IDStormwater Drainage ft. ft.
®Experimental Technology QlSubsidence Control ft. ft.
*Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary) . -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
al Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 90 ft. Clay
4.Date Well(s)Completed: 06/21/23 Well ID# 90 ft• 605 ft• Granite
5a.Well Location: ft ft.
Ron Severs ft. ft. ,t r< ri T f v.n
Facility/Owner Name Facility Mg(if applicable) ft. ft. ' °'"'-'L.;""
155 Tanglewood Heights Brevard 28712 ft. ft. - JI,JI 0 `? ZuZ3
Physical Address,City,and Zip ft. ft. _ ,'taR fir.^,^s, t, ? (;rc
Transylvania 8597-02-7461 21.REMARKS- r_, ... ^`k�'
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: '
35.268 N -82.716 w
06/21/23
6.Is(are)the well(s) Permanent or Temporary Si tore of Certified W 1 Contractor Date
By signing this form,I hereby cergr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes or XjNo with 15A 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#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.
filled'r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (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 top of casing: 300 (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 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) 1/2 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: 109 tabs completion of well construction to'the county health department of the county
where constructed.
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016