GW1--05091_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES _ -
Well Contractor Name FROM TO DESCRIPTION
0 ft. 305 it 4gpo
2418
305 ft• 385 ft. 1
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 ft. 77 ft. 61/4 tn. PVC
W I OSS-2023-0514 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): ft. ft. in.
Water Supply Well: 17.SCREEN ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring 0 Recovery ft. it.
Injection Well: ft. ft.
Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery O Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
' Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness soil/rock type,srrin size etc.)
0 ft. 77 ft. Clay
4.Date Well(s)Completed:06/23/23 Well ID# 77 ft• 405 ft* Granite
ft. ft.
5a.Well Location:
mob»; •-
Mary Drake/More than a Carpenter LLC ft. ft. 1,,,-I
• t,_,o 'off� d-. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.242 Ore Brae Ln. Hendersonville 28739 ft. ft. AUG 0 i 2023
Physical Address,City,and Zip ft. ft. 1iNc.":; .1)C•ci Pr.^.,-fs,�o^.:'.'3)U1*
Henderson 9557-69-6809 21.REMARKS D1,VCtr3t..a.;
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.Ce ' lion:
35.293 N -82.499 w
�� 06/23/23
6.Is(are)the well(s)'Permanent or °Temporary
Signature ofCeertified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or X°No 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#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:r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (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: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 (in.) 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) 5 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: 74 tabs completion of well construction 4O 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