GW1--06661_Well Construction - GW1_20231006

.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATERZONES -
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 225 ft. rpm
4238 ft. ft. I
NC Well Contractor Certification Number .15.OUTER CASINO(for LINER Of an ltcable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 109 it61/4 in. Steel
Company Name .
W EL20 9-00 40 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. i in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER l SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring 0Recovery ft. ft.
Injection Well: ft. ft. •
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL,PACK(if applicable) , .
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I1Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) I0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
0 ft. 109 ft. Clay
4.Date Well(s)Completed:09/05/23 Well1D# 109 tt• 305 ft* Granite
ft. ft. , l._',.w:k.., 1:::'r E V t
5a.Well Location:
Mayley Cruz ft. ft. OCT 0 6 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
11 Caleb Dr. Candler 28715 ft. ft. iiIcoa 'vca ar.:- .5,14 .-.3 U
ft. ft.
Physical Address,City,and Zip
Buncombe 9615-09-3516 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.Certification:
35.507 N -82.662 W es, 09/05/23
at
6.Is(are)the well(s) Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this forma,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JJYes or [jNo 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diflerent(example-3@200'and 2@100') ' construction to the following:
10.Static water level below top of casing: 10 (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.) 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' 56 tabs completion of well construction to the county health department of the county
where constructed. 1
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016