GW1--04356_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: r-
1.Well Contractor Information: •
Robin Webb 14.WATER ZONES ,. •
Well Contractor Name FROM TO DESCRIPTION
0 ft• 665 ft. u
prn
2418
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• 80 ft* 61/4 I in. PVC
Company Name
WEL2023-00074 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.UIC,County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): it. ft. rn-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural jMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in. '
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT' .: - - '
! Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
Monitoring -0 Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 01Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) o g• 60 ft• Clay
4.Date Well(s)Completed:06/12/23 Well ID# s0 ft• 685 ft' Granite
5a.Well Location: ft. ft.
Doug Flaherty/Lakota Denton ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 7/ c i Wit,
1397 Newfound Rd. Leicester 28748 ft. ft. p "p"r 9
ft. ft. J IJ I 0 7 2023
Physical Address,City,and Zip
Buncombe 8689-32-3536 21.REMARKS
lnfoc r sicn r+r.::r ;F:�Urt
County Parcel Identification No.(PIN) rDi ai,^rnr'y4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C r tea'on:
35.591 N -82.749 w
-147t -D 06/12/23
6.Is(are)the well(s) Permanent or Temporary Signature fCertificd a antra or 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: [JYes or EiNio with 15A 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 ojthe 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: 685 (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: 150 (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 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) 30 Method of test: 2 hours 24c.For Water Supply&Iniection 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: 124 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