GW1--05094_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER zoNEs-
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 120 ft. ,og,,,,
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. 63 ft. 61/4 in. Steel
Company Name ^ n
SAS-237 V V 16.INNER CASING OR TUBING(geothermal closed-loop) ' ,' •
2.Well Construction Permit#: v7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: k 17.SCREEN'
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. i .
ln
Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) ft. ft. in.Industrial/Commercial OResidential Water Supply(shared) 18.GROUT . . -
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' Bentonite
Monitoring 0Recovery ft. ft.
Injection Well: •
ft. ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology . QSubsidence Control ft. ft.
Geothermal(Closed Loop) DITracer 20.DRILLING LOG(attach additional sheets if necessary) -. .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock typo grain size etc.)
0 ft. 63 ft. Clay
4.Date Well(s)Completed:05/30/23 Well ID# 63 ft• 145 ft. Granite
rr*
5a.Well Location: ft. ft. R ?"":4--i• .,...,
••
°
t. � t-- a
Tony Hooper ft. ft. .. s y _
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft. AUG 0 A �023
415 Orion Davis Rd.Waynesville 28786 ft. ft. 1ft:Mui^rl Prr-^4 ng Utwi
Physical Address,City,and Zip ft. ft. DW$i;/3
Haywood 7694-25-9453 zl.xEinARxs.
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:
35.456 N -83.054 �, 1
c.4 -
‘)4.0 ,A, 05/30/23
6.Is(are)the well(s){Permanent or jTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerdfi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or XONo 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 145 (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: 30 (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 Infection 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) 10 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: 25 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