GW1--05096_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. 65 ft. tagpm
2418
ft. ft. I
NC Well Contractor Certification Number '"15.-OUTER CASING(for multi-cased wells)OR LINER(if ap nimble)
Greene Brothers Well & Pump,WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
—— 0 ft. 51 ft. 61/4 in. PVC
Company Name
M C n I�IVIA—'F V V^ n'03, .16.ENNER CASING OR TUBING(geothermal closed-loo)).
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
11,Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) fL ft. in.
*Industrial/Commercial DResidential Water Supply(shared) ls:GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
*Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
aiAquifer Recharge D Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
IlAquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
RI Aquifer Test J Stormwater Drainage ft. ft.
*Experimental Technology OSubsidence Control ft. ft.
*I Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
III Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 51 ft. Clay
4.Date Well(s)Completed:07/12/23 Well ID# _ - 51 ft- 105 ft• Granite
5a.Well Location: ft. ft.
Steve London ft. ft. rR- :1
r.,
1'"
Facility/Owner Name Facility ID#(if applicable) ft. ft.
156 High Top Dr. Canton 28716 ft. ft. AUG ) /< 1023
Physical Address,City,and Zip ft. ft. ligt1M7i-n Pfr-^.b...i•*sr i t rt
_t'v
Haywood 8653-83-2777 21.REMARKS r^vaSv�,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Ce tilication:
35.430 N -87.833 w f AA, ( Q 07/12/23
6.Is(are)the well(s)*Permanent or DTemporary Signature of Certified Well Contrac 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: [JYes or [ No 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: 105 (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 ureter 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) 13 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: 18 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