GW1--05095_Well Construction - GW1_20230804

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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. 425 ft• ll4 avm
2418
425 ft• 965 ft. 1/4gpm
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. 80 ft• 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING'(geothermal closed-loop)
2.Well Construction Permit#: JMQ-306W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Count,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 DMunicipaIPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
• 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0IStormwater Drainage ft. ft.
Experimental Technology I0Subsidence Control rt. ft.
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) 0l Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ere.)
0 ft. go ft. Clay ,
4.Date Well(s)Completed:07/11/23 Well ID# 80 ft• 1,105 ft" Granite
5a.Well Location: ft. ft.
John Reed/Sharp Builders ft. ft. -- .�1�;
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ._�,,. e...a `lr 4.®t,,�
235 Flat Creek Ln. Canton 28716 ft. ft. AUb ® A 2023
Physical Address,City,and Zip ft. ft. Infr.r-ma'iti.:l Prr-..�..7,;4,„ U u:
Haywood 8663-55-1976 21.REMARKS • GV,a'»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.Certification:
35.438 -82.810
N w `�l'a-C 9- 07/11/23
6.Is(are)the well(s)JPermanent or JTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: i Yes orjNo 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:
S.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: 1,105 ft,
P ( ) 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:455 (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 r 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) 112 Method of test: 2 hours 24c.For Water Supply&Infection 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: 200 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