GW1--05938_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
Travis Greene
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1.4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 80 ft. 2gcm j
4238
80 ft. 365 ft. gpm
NC Well Contractor Certification Number 'IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) '
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 72 ft 61/4 i in. PVC
Company Name ,t
21 t 1201 O$'t4$ '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.UJC,County,State,Variance,etc.) ft. ft. I in.
1 i
3.Well Use(check well use): ft. ft. I ,in.
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'17.SCREEN
Water Supply Well: FROM I TO DIAMETER ; SLOT SIZE EMATERIAL THICKNESS
,®,Agricultural E3Municipal/Public ft. ft. in:
MI Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in: '
$ilndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
I 'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
. ill Monitoring JRecovcry It. ft.
Injection Well:
ft. ft. -
*iAquifer Recharge Di Groundwater Remediation
��-, 19.SAND/GRAVEL PACK(if applicable)
L
ill Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
NI Aquifer Test E3Stormwater Drainage ft. ft.
111 Experimental Technology ID Subsidence Control ft. ft. ' I 1 -
ili Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessary) -
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/roek type Praia size etc)
o ft. 72 ft Clay
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4.Date Well(s) 07/25/23 ft.Completed: Well ID# 72 405 ft. Granite; E.,., i"',..
5a.Well Location: ft. ft. �• ly
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Maria Salas ft. ft. SEP j 9 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
in i; 3;.l.:v t r..;',.,,
107 Hibiscus Hill Dr. Hendersonville 28792 ft. ft. CN :'ti.'` U'rtet
Physical Address,City,and Zip ft. ft. I
Henderson 9670-46-9319 21.REMARKS ..
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: ,\ r
35.367 N -82:439 W '
y ��,� vR 07/25/23
6.Is(are)the well(s)JPermanent or DTemporary Signature of Certified Well 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: IYes or E1.10' 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: 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: t
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/4 '
11.Borehole diameter: (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: y '
(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) 6 Method of test: 2 hours 24c.For Water Supply&Injection I Wells: In addition to sending the form to
r 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 to the county health department of the county'
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016