GW1--07343_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 305 ft• s gpm
2418
305 ft• 505 It* .5ow' 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)'OR LINER(if applicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 87 ft' 61/4I in. PVC _
Company Name ' 16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: 202 -2 633-9-� 385 FROM TO DIAMETER THICKNESS MATERIAL •
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ' . in.
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3.Well Use(check well use): ft. ft. i ' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
ill Agricultural iDMunicipal/Public ft. ft. in.
Geothermal �I� (Heating/Cooling Supply) �jC Residential Water Supply(single) ft. ft. in.
•Industrial/Commercial -� DResidential Water Supply(shared) 18.GROUT. . -
j I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ,ft- Bentonite
•Monitoring DRccovery ft. ft.
Injection Well:
ft. ft.
•Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
it Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test I StormwaterDrainage ft. ft.
ill Experimental Technology Ell Subsidence Control ft. ft.
•Geothermal(Closed Loop) IJTracer 20.DRILLING LOG(attach additional sheets if necessary)'. ',
*Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type.groin size etc.)
0 ft. 87 ft, Clay
4.Date Well(s)Completed: 09/27/23 Well ID# 87 ft• 545 no Granite
' ft. ft.
5a.Well Location: _,. ----. ._. __
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Jackie S Hart Trustee/Donnie Lowery ft. ft. a ,.`�y,n S„_ i F� ll „ „•
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV 1 c„ 2023
827 Spruce Flats Rd. Maggie Valley 28751 ft. ft.
Physical Address,City,and Zip ft. ft. info ;r .^'1 ;;". . _ ,-.3 1 n 1
Jackson 7665-19-7066 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. • :lion:
35.490 N -83.159 W / -
x�,�, 09/27/23
6.Is(are)the well(s)lPermanent or Temporary Signature of Certified Weri on i)4,_
Date
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 OX©No 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: 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: 60 (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
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 iCenter,Raleigh,NC 27699-1636
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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: 99 tabs- completion of well construction Ito!the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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