GW1--06589_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: (,� .f ~
I
1.Well Contractor Information: I
Robin Webb '-14:WATERZONES • -
Well Contractor Name FROM TO DESCRIPTION
0 ft. 305 ft. yam f
2418
305 ft 485 ft. 397m 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 57 ft. 61/4 1° PVC
DGS-036W •
M.INNER CASING OR.TUBING(geothermal closed-loop) •
2.Well Construction Permit#: `7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) _ ft. ft. j in.
3.Well Use(check well use): ft. ft. in.
-117.SCREEN _
Water Supply Well: FROM TO DIAMETER. SLOT T SIZE THICKNESS MATERIAL
,!Agricultural OMunicipal/Public ft. ft. in.
I
*Geothermal(Heating/Cooling Supply) OIResidential Water Supply(single) ft. ft. in,
MI Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
*I Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
*Aquifer Recharge I©IGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test 0 Stormwater Drainage ft. ft.
*.Experimental Technology [Subsidence Control ft. ft.
*Geothermal(Closed Loop) LITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
0 ft. 57 ft. Clay
4.Date Well(s)Completed:08/29/23 Well ID# 57 ft. 505 ft. Granite)
ft. ft. tr..;- t ! -i! . . r• ' -',
5a.Well Location: '•' ;•4 s :., :;,fi,. V r" ;
Kuno Von Duerckheim ft. ft.
Facility/Owner Name " Facility ID#(if applicable)
ft. ft. O C T 0 kr 2023
158 Morrow Mountain Rd.Waynesville 28785 ft. ft. ln;:,,'.;7.4i:7n ? : =f3 Un
Physical Address,City,and Zip
ft. ft. EA:ee.xt2,:Jt�
Haywood 8627-36-6621 21.REMARKS ' • . . '
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.C•: I.cation:
35.544 N -82.955 w ' C::)_61:)
08/29/23
Temporary Signature f Certified Well Contractor Date
6.Is(are)the well(s)JPermanent or
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: DYes or [$No with 15A 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 tire 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:' i
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 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)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 ' )
(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) 8 Method of test: 2 hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit Rorie 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. i '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources '1
Revised 2-22-2016