GW1--05088_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
i
Travis Greene 14:wATERzoNEs
FROM TO DESCRIPTION
_ Well Contractor Name
. 0 fL 200 ft- y4�m
4238
• ft. ft.
NC Well Contractor Certification Number • 15:;Q0'iT:R"CASING;(fotmulti;cased',wells)'OR'ILIIYER"(if ap'lleableY"=-::::' ':-:';}::_;:.
Greene Brothers Well &Pump,WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 22 ft. 61/4 in. PVC
Company Name
WI22120103266 161:INNEIMASING:OR--TUBING(geothermal elosedaoiip)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable He construction permits(.e.UIC,County:State,Variance,etc.) ft. it. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: FROM
REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural °Municipal/Public ft. ft. in.
X Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) Is,, ft. in.
'Industrial/Commercial °Residential Water Supply(shared) c18,GROUT
L.t Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft• Bentonite
II Monitoring °Recovery fL ft.
Injection Well:
ft.
it Aquifer Recharge °Groundwater Remediation
".19:SAND/GRAVEL-PACK:(if applicable)
NI Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
a•Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology (0Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer :20 DRILI:ING LOG(attaetr"additional stieetitsifneeess>fr"y) `'
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size.etc.)
3Geothenpal(Heating/Cooling Return) °Other(explain under#21 Remarks) o fL n it. Clay
4.Date Well(s)Completed:07/20/23 Well ID# 22 ft. 985 ft Granite
5a.Well Location: •
ft. ft.
Adam Toney ft. ft. Pi— .•17..1 i dam
Facility/Owner Name • Facility m#(if applicable) ft. ft. �' "�"e V 1_U
Randy Dr. Hendersonville 28791 ft. fL AUG 0 t` 2023
Physical Address,City,and Zip ft. Inik , a ir,n pr
Henderson 9650-92-6715
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:
35.356 N -82.489 W q 07/20/23
6.Is(are)the well(s)JX Permanent or EDTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or PjNo with ISA 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 of the copy of this record has been provided to the well owner.
repair under 421 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.
dulled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 985 (ft) 24a. For All Was: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3Q200'and 2(42I00') construction to the following:
10.Static water level below top of casing:600 (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 Cm.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary above,
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) 3/4 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: 180 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