GW1--07345_Well Construction - GW1_20231113

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
Travis Greene
14.E WATER ZONES . `"-
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 1eo ft. morn 1
ft. ft.
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
0 ft. 101 ft. 6 1/4! in. PVC
- Company Name p - _
OOS-2023-1 173 •16.INNER CASING OR TUBING'(geotbermal closed-loop). . ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,'etc.) . ft. ft. i in.
3.Well Use(check well use): ft. ft. ' in.
Water Supply Well: 17rSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS 1 MATERIAL
Agricultural OMunicipal/Public ft. fL in.
I
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.'
Industrial/Commercial DResidential Water Supply(shared) .
18.GROUT,`'. .' ,
f_ Irrigation % FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o , ft• 20 ft• Bentonite
- Monitoring DRecovery ft. ft.
Injection Well: ft. , fL
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable): .
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test jStormwater Drainage ft. ft.
Experimental Technology ID Subsidence Control ft. ft.
Geothermal(Closed Loop) IJTracer '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• 101 it Clay
4.Date Well(s)Completed: 10/06/23 Well ID# 101 ft• 245 ft- Granite
5a.Well Location: r ft. ft.
Mitchell Gaiter& Rick Moore ft. ft. f: _ ; :'
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO
V
78 Byron Forest Ln. Mills River 28742 ft. ft. Z023
Physical Address,City,and Zip
ft. ft. lnf::1,s.i^❑ ;ate r;?;z.n i!r:,i.
Henderson ' 9630-80-1724 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:
35.349 -82.559
N W 10/06/23
Lee..-,1 ' �_--
6.Is(are)the well(s) Permanent or JTemporary Signature of Certified Welk ontractor Date
By signing this form,I hereby cert j that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• jYes orONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Weil 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: 245 (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 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) 20 Method of test: 2 hours 24c.For Water Supply&Iniecti In(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: 43 tabs completion of well construction to I 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