GW1--05945_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: 1
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Robin Webb ,14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 225 ft.
2418 ft. ft. f 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if an llcabte)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 107 ft' 61/4 1 ,in. PVC
Company Name ".16.INNER CASING OR TUBING(j eothermal closed-loop):
2.Well Construction Permit#: GJ B-1 89W 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
%.Agricultural OMunicipalPublic ft. ft. is
a Geothermal(Heating/Cooling Supply) EI1Residential Water Supply(single) ft. ft in.
*i Industrial/Commercial DResidential Water Supply(shared) 18.GROUT ,
j ;Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
aIMonitoring IDRecovery it. ft.
Injection Well: ft, ft.
alIAquifer Recharge EiGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
all Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ill i Aquifer Test i®IStormwaterDrainage ft. ft.
%Experimental Technology 0Subsidence Control ft. ft.
*i Geothermal(Closed Loop) OTracer "20.DRILLING LOG(attach additional sheets if necessary) '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
MI Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft 107 ft. Clay
4.Date Well(s)Completed:05/24/23 Well ID# 107 ft 245 it Granite.
5a.Well Location: ft. ft. .-�,s'�*Na�f!___ i► r, , �
• ft. ft. '' t...{ 4/ �� Li}
. Terri McQuiddy
Facility/Owner Name Facility 1D#(if applicable) ft. ft. S E P 1 2 7023
151 Quail Court Canton 28716 ft. ft.
Physical Address,City,and Zip ft. ft. [r"rs'01.104,1
Haywood 8678-26-9363 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.C• i[cation:
35.575 -83.791 ill N W 1 c 05/24/23
t. J
6.Is(are)the well(s) IPermanent or OTemporary 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: IjYes or ONo 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:1 SUBMITTAL INSTRUCTIONS ..
9.Total well depth below land surface: 245 (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:40 (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.) -
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 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: 43 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