GW1--05946_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
6 t
Robin Webb "."14.WATER ZONES ` ' ' -
Well Contractor Name FROM : TO DESCRIPTION
0 ft. 305 fL seam
2418 -
305 ft. 485 ft. 1s.5 gpm ` ,
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 H. 65 ft. T
61/4 I: ' in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) . -:
2.Well Construction Permit#: GJ B-183W 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
Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. i
*I Industrial/Commercial °Residential Water Supply(shared) 18.GROUT_
I... I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
**Monitoring ORecovery • ft. ft.
Injection Well:
ft. ft.
$I Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
MI Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ji!Aquifer Test °Stormwater Drainage ft. ft.
*Experimental Technology °Subsidence Control ft. ft.
*Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) '•
III Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sai/rock type,grain size,etc.)
0 fL 65 ft. Clay 4
4.Date Well(s)Completed:07/26/23 Well ID# 65 ft* 505 ft' Granite
ft. ft. 4 t :,£"' /tom D
5a.Well Location: �' ��'l,r�`- : � "��+•
Mary Irvin ft. ft. p j 2'/
Facility/Owner Name Facility ID#(if applicable) tt ft r 1 C 02�
90 Last Coyote Trail Canton 28716 ft. ft. lr :it*>,71 Pr.,, ,4a i,r
Physical Address,City,and Zip ft. ft. ��vJ'�'etlin
Haywood 8644-95-6849
•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.Ce ., I on: I
35.463 N -82.864 W,
-,too 07/26/23
6.Is(are)the well(s)jjPermanent or °Temporary Signature of Certified Well Contractor : Date
By signing this form,I hereby cent fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or °C No with ISA NCAC 02C.0100 or ISA 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#11 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20200'and 2@100) construction to the following:
(
10.Static water level below top of casing: 1 ',►V (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 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: 2 hours 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 92 tabs completion of well construction to the county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016