GW1--05092_Well Construction - GW1_20230804

i =r=rrrr r-r1./11" -q
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb ::14:.WATER'ZONES
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 185 ft• 15san 1 1
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. go ft. 61/4 in' PVC
Company Name
16.INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: GJ B-1 82W 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. it. in.
.
Water Supply Well: .17.SCREEN,FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ill Agricultural OMunicipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.,
NI Industrial/Commercial OResidential Water Supply(shared) 18.GROUT -. ;
! 1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Bentonite
*Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
*Aquifer Recharge D Groundwater Remediation
•.19.SAND/GRAVEL PACK(if applicable)
%I Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*i Aquifer Test 0Stormwater Drainage ft. ft,
®Experimental Technology 0 Subsidence Control ft. ft.
**Geothermal(Closed Loop) DITracer 20.DRILLING LOG(attach additional sheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) EllOther(explain under#21 Remarks)
o it go ft. Clay
4.Date Well(s)Completed:07/04/23 Well ID# 80 ft* 205 ft' Granite
ft. ft.
5a.Well Location:
Lucas Kyle ft. ft. Km a LTV'h f`'i
Facility/Owner Name Facility ID#(if applicable) ft. ft.
145 Riversedge Way Canton 28716
ft. ft. ,UG 0 z 2023
ft. ft. Ink;;.ic.'u,•'zn Prr.•:w#:s,e ur:it
Physical Address,City,and Zip �t.1 •,J,`Haywood 8644-68-9965 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:
35.471 N -82.873 W , 07/04/23
6.Is(are)the well(s)OPermanent or Temporary
Signs a of Certified ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or ONo 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 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: 205 (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:25 (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) 15 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: 36 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