GW1--05944_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: 1
• Robin Webb ,14.WATER ZONES if I
Well Contractor Name FROM TO DESCRIPTION,
0 ft. 285 ft. 25spm ` 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. 66 fL 61/4 : in• Steel
Company Name '16:INNER CASING OR TUBING(geothermal closed-loop) • '
2.Well Construction Permit M CM-394W 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. I in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKI�FSS MATERIAL
Agricultural lMunicipal/Public�X( ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
lndustrial/Commercial DResidential Water Supply(shared) 17.SCREEN -
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
*Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
MI Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0IStormwater Drainage ft. ft.
il Experimental Technology 0 Subsidence Control ft. ft.
i
ill Geothermal(Closed Loop) ItTracer 20.DRILLING LOG(attach additional sheets if necessary)- '
MI Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type gain size eta)
0 fL 66 ft• Clay
4.Date Well(s)Completed:051/04/23 Well ID# 66 ft. 305 ft. Granite
ft. ft. !,Y "( 17"':i r ' r)
5a.Well Location:
Jose Serafim/Ben Wilson ft. ft. -` ' ,. ..',,1,,,,.e.,,
Facility/Owner Name Facility ID#(if applicable) ft. ft. SEP 1 G 2023
12674 Cruso Rd. Canton 28716 ft. ft. In4;,.xa i.I,n 3rr.,,,s.w/'a,(>►,-7*
Physical Address,City,and Zip
ft. ft. Dtf.IO��''..liiz 3
Haywood 8663-42-0195 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. :lion: '
35.426 N -82.813 W
- •61L, C 01/04/23
6.Is(are)the well(s)EPermanent or QITemporary Signature of Certified well Contractor Date
By signing this form,1 hereby certify that the nrll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JjYes or XONo 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: 305 (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(4)100') construction to the following:
1
10.Static water level below top of casing:40 (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 I '
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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 25 Method of test: 2 hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subniitI one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 56 tabs completion of well construction io 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