GW1--06587_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I .
Robin Webb 14.WATERZONES -
Well Contractor Name FROM TO DESCRIPTION ,
0 ft. 205 ft. sgpm 1
2418
205 tt• 500• f6 agp. I,
NC Well Contractor Certification Number .15 OUTER CASING(for multi-eased welts)OR LINER(If ap 'feeble)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 ft- 61/4 6 : in' PVC
Company Name
DGS-047 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. l' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
J FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
!Agricultural. OMunicipal/Public ft. ft. iii.
*'Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft. in.
*IIndustrial/Commercial °Residential Water Supply-(shared) 18.GROUT
I, Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well: 0 ft. 20 ft- Bentonite
liIMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
lIAquifer Recharge °Groundwater Remediation '
-19.SAND/GRAVEL PACK(if applicable)...
®I Aquifer Storage and Recovery fDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test ID Stormwater Drainage ft. ft.
*Experimental Technology Et Subsidence Control ft. ft. } ,
NI Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)` _ - '
11 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type krain s ze etc.)
0 ft. 40 ft- Clay 1
4.Date Well(s)Completed:09/07/23 Well ID# 40 ft. 545 R Granite
Sa.Well Location: ft. ft. I � '",,i`IYR11r.,.,-,,
Ron Hill ft. ft. OCT °_
Facility/Owner Name -Facility ID#(if applicable) ft. ft. i OCT I 0 t) Z11t3
7363 Carolina Blvd..Clyde 28721 ft. ft. (t'fJ r l t r: ,2,�, ,7 h r!
Physical Address,City,and Zip ft. ft. i l3 v�.y
- Haywood - 8647-10-8006 zi:ltEMA1tKS
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: 1
35.528 N -82.893 w
09/07/23
e o >61:.)IL
igna . of Certified e Date
6.IS(are)the wellXs) Permanent or OT mp rary
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: JYes or CiNo with 15A NCAC 02C-.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis 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 i
9.Total well depth below land surface: 545 / (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:20 (ft.) Division of Water Resources,es,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh;NC 27699-1617
I
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) 1 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: 99 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