GW1--05090_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Travis Greene -;14.WATER ZONES •
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft 240 ft. eyum
ft. It.
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. 150 ft. 61/4 in' PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSS-2023-0236 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. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
All Agricultural DMunicipal/Public ft. ft. in.
11,Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft in.
al Industrial/Commercial DResidential Water Supply(shared) 18.GROUT -
' 'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
giMonitoring DRecovcry ft. ft.
Injection Well:
ft. ft.
MI Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
111IAquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
NI Aquifer Test 0IStormwaterDrainage ft. ft.
MI Experimental Technology 0 Subsidence Control ft. ft.
II Geothermal(Closed Loop) DITracer 20.DRILLING LOG(attach additional sheets if necessary)
11 Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Other(explain under#21 Remarks)
0 ft- 150 ft. Clay
4.Date Well(s)Completed:06/14/23 Well ID# 150 ft. 285 ft.
Granite
5a.Well Location: ft. ft. _, +..,,,�;—4 tY�. y+
Moore&Son Site Contractors LLC ft. ft. AUGe�� 3
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft. AUG U au
80 Banner Cottages Ln. ft. ft. oer,, p,, Urtit
Physical Address,City,and Zip ft. ft. C5WC1i ' a
Henderson 9630-70-8164 .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:
35.346 N -82.562 W
06/14/23
mporary Signature ofCertified Well Contractor Date
6.Is(are)the well(s)JPermanent or DITe
By signing this form,I hereby cert(f that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or jNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall 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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (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@I00') construction to-the following: ,
10.Static water level below top of 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 (tn.) 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) 6 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: 51 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016