GW1--07348_Well Construction - GW1_20231113

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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 ,
2418 0 ft. 405 ft• 66«gpm 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. 81 ft. 61/4 in. Steel
Company Name ,
OSS-2023-0936 16.INNER CASING OR TUBING(geothermal closed-loop) .
2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS MATERIAL -
—
List all applicable well construction permits(i.e.UIC,Calmly,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. I in.
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Water Supply Well: 17.SCREEN
�iAgilCUltUIal Munici FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
pal/Public ft. ft. I in.
I*1 Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft ft. I in.
*II Industrial/Commercial DResidential Water Supply(shared)
18.GROUT =
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft' Bentonite
*Monitoring ORccovery ft. ft.
Injection Well: .
ft. ft.
*Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*I Aquifer Test QStormwaterDrainage ft. ft.
lIExperimental Technology 0ISubsidence Control ft. ft. i
*Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessar
y) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
11 Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 it. 61 it. Clay
4.Date Well(s)Completed: 10/17/23 Well ID# 61 ft• 425 ft' Granite
5a.Well Location: ft. ft.
Ken &Carol Scranton ft. ft. i
Facility/Owner Name Facility DM(if applicable) ft. ft. ;t,e-• , "s S;N v. 1
., Y Y. : _1
105 Joyce Rd. Hendersonville 28792 ft. ft. I,
Physical Address,City,and Zip ft. ft. i Iv v v 1 Z023
Henderson 9661-50-3581 21.REMARKS
`_' Cli
County Parcel Identification No.(PIN) D';``./-.! ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I I
(if well field,one latflong is sufficient) 2 ertifica i,,n•
35.378 -82.471
N W IIIMI. � Q' r 10/17/23
6.Is(are)the well(s) IPermanent or Temporary Signature ertrfied welTContractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes or QNo 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 the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS 1 I
9.Total well depth below land surface: 425 (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@I00) construction to the following: I
10.Static water level below topcasing: 5
of (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
12.Well construction method:
Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 60+ Method of test: 2-hours 24c.For Water Supply&Inlectioni 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: 78 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 Revised 2-22-2016
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