GW1--07351_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD (GW-il
For Internal Use Only: '
1.Well Contractor Information: I
-14:WATER ZONES : - F`''
Roble Webb FROM TO DESCRIPTION I I
Well Contractor Name -
0 ft. 425 ft.
2418 •
425 ft. 645 ft.
EMIIIBIMIIIIINIIIIIIIIIIIIII
- NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a.,licabte
FROM TO DIAMETER I THICKNESS
o
Greene Brothers Well &Pump,WT Inc. ft. 95 fL 61/4 ill 11111111111211111111111Company Name -'16.INNER CASING OR TUBING :eothermal lose IESS
JMQ-313W FROM TO DIAMETER ;' THIC-
• 2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. IIIIIIIIIIII
ft ft. ®MINII
3.Well Use(check well use): IIIIIIIIIIIII
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIALWater Supply Well: ft. ft. is r
in.
I,ii Geothermal(Heating/Cooling Sup
Agricultural OMunicipal/Publicumm1E —
�I Residential Water Supply(single) {{ ft.
ply) 1 ..
�ilndustrial/Commercial
Residential Water Supply(shared) 18:GROUT• EMPLACEMENT METHOD&AMOUNT
FROM 0 FROM TO ft, 20 ft
i
Non-Water Supply Well: fL ®�
$iMonitoring Recovery
11111111111111111111
ft. ft.
Injection Well:
ill Aquifer Recharge Groundwater Remediation 19.SAND/GRAVELPACK if a licable TO MATERIAL EMPLACEMENT METHOD*iAquiferStorageandRecovery D Salinity Barrier FROM ft. ftN I Aquifer Test 0 Storniwater Drainage ft.
IIIIIIIIIIIII
*Experimental Technology Subsidence Control
ft.
20:DRILLING LOG attach oddttionalslieets if necessa in size,etc.
1.111111111111111111111
**Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTIONalsheets
is if necessahardness,soiV- . r~_
• II,Geothermal(Heating/Cooling Return) all Other(explain under#21 Remarks) .o ft. 95 ft.
10/04/23 lllD#
4.Date Well(s) � Well 111
Completed: — 95 ft- 665 ft.ft. ft.
5a.Well Location: ft. ft.
Dream Valley Properties,LLC
IIIIIIIIIIIIIIIIIIIIEIIIEOIM
Facility/Owner Name ft. ft.Facility ID#(if applicable)
ft. ft.
410 Dream Valley Dr. Clyde 28721 ft. ft.
Physical Address,City,and Zip 8711-64-3964 21'REMARKS
Haywood
Parcel Identification No.(PIN)
County111111111111111111111111111111111111111.1111
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22. cation
(if well field,one lat/long is sufficient) 10/04/23
35.649 N -82.983 w
Signs ofCertifi
clot ' Date
6.Is(are)the well(s)!Permanent or (oTemporary
By signing this form,I hereby certinl that the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and tlra!a
If Is thiss a repair outto an existing well:
Yes or Jj No copy 5Af is record has been provided to the well owner.
If this is a repair,fill known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. You may use the back of this page to provide additional well site details or well
of wells construction details. You may also attach additional pages if necessary.
8.For Geon,only 1 or Closed-Loop Geothermal Wells having the same i
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBERS�__,P,PAL INSTRUCTIONS i
drilled:' of completion of well
9.Total well depth below land surface: 665 (ft.) 24a. For All Wells: Submit his tform within 30 days P
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following:
(ft) Division of Water Resources,Information Processing Unit,
I0.Stalk water level below top of casing:220 1617 Mail Service'Center,Raleigh,NC 27699-1617
If inviter level is above caa sing,use"+"
6 1/4 (in.) 24b.For Injection Webs: In addition to sending the form to the address in 24a
11.Borehole diameter: above,also submit one copy ofi this form within 30 days of completion of well
12.Well construction method:
Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resource's,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: i.
4 Method of test 2 hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Amount•120 tabs completion of well construction to the county health department of the county
13b.Disinfection type: HTH where constructed. I Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1 .