GW1--06582_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb `
`I4:WATER ZONES ,
FROM TO DESCRIPTION
Well Contractor Name
o ft. 105 ft* sa,m
2418
105 it 205 ft• s gpm 1
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
Company Name 0 ft. 27 ft• 61/4 . rn• PVC
DGS-051 W 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.UIC,County State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. 1 in.
i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural Mwucipal/Public ft. ft. Iin.
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) ft. ft in.i
i
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
L. IrrigationR FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
1IMonitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
I_. Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20:DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)3 FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 27 ft. Clay
4.Date Well(s)Completed:09/15/23 Well 1D# 27 ft 605 it Granite
. r
, 5a.WellLocation: ft. ft. N. .Y.,• `� _ n,-..�_{e
Eliot York ft. ft. OCT
; 2923
Facility/Owner Name Facility ID#(if applicable) ft. ft.
55 Percy Way Clyde 28721 ft. ft. I In„ii-Fr._1'cn r-1 c*Cfig 9 iJn:
Physical Address,City,and Zip
ft. ft. �`:sr:::1 v
Haywood 8732-55-5955 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. cation:
35.668 N -82.923 1
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( A, 09/15/23
6.Is(are)the well(s)JPermanent or DITemporary tgna of Certified Wel Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or IDNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Obis 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 1
9.Total well depth below land surface: 605 (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@I00') construction to the following:
10.Static water level below topof 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 Iniection Wells: In addition to sending the form to the address in 24a
Rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e,auger,rotary,cable,direct push,etc.) construction to the following: I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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: 109 tabs completion of well construction to Ithe county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016