GW1--07355_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
raviS Greene ., 14.WATERZONES .
FROM . TO DESCRIPTION
Well Contractor Name 0 ft. 280 ft. I _,
4238
/ ft. ft. '
NC Well Contractor Certification Number '15:.OUTER.CASING(for'multi-casedivells):OR LINER(if ap Ilcab)e) " - '
Greene Brothers Well &Pump,WT Inc. FROM TO DIAMETER• THICKNESS MATERIAL
0 ft. 89 ft. 61/4 I' in' PVC 1
Company Name 16:'INNER CASING OR TUBING(geothermal closed-loop)' `
2.Well Construction Permit#: MCM-398W FROM TO DIAMETER' THICKNESS MATERIAL
, List all applicable well construction permits(i.e.UIC,Count;State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft ft. in.
t';17.SCREEN - ;:: ..
Water Supply Well: ,
FROM TO DIAMETER I' 'SLOT SIZE ' THICKNESS MATERIAL
it Agricultural • }Municipal/Public ft. ft. in•I I
IX Geothermal(Heating/Cooling Supply) IDIResidential Water Supply(single) ft ft. in.i,
Ri Industrial/Commercial [Residential Water Supply(shared)
t 1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ) . 0 ft. 20 ft• Bentonite
MI Monitoring DRecovery ft.. ft.
Injection Well: •
ft. •ft. .
NI Aquifer Recharge DGroundwater Remediation '
19.SAND/GRAVEL PACK(if applicable) -
MtAquifer Storage and Recovery I0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• fiiAquifer Test 0Stormwater Drainage ft. ft. ' '
a Experimental Technology D Subsidence Control ft. ft. • I i
all Geothermal(Closed Loop) DTracer 20 DRILLING LOG(attach additional sheets if necessary)•' '
FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,etc.)
)r Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
p ft. 39 ft. Clay II I
4.Date Well(s)Completed:09/12/23 Well ID# 39 ft 305 ft Granite
5a.Well Location: ft ft.
NOL.,
Cynthia Chastain ft. ft.
is `�-� .." pe `�_. j
f �>
Facility/Owner Name Facility ID#(if applicable) ft. ft I• ti 2�23
575 Incinerator Rd. Clyde 2872.1 '
ft ft. I C7':•1:: y3'':i i-;i3:1
Physical Address,City,and Zip •
' Haywood ' 8657-07-9108 _,2r:;REMARKS -:c
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. ation:
35.549 N -82.864 ' W _
09/12/23
6.Is(are)the well(s)JPermanent or IITemporary Signa o Certified ell ontractbr Date
By signing this form,I hereby certi9 that the well(s)was(were)constructed in accordance
•
7.Is this a repair to an existing well: IJYes or XI 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' 1
9.Total well depth below land surface: (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: 4C
10.Static water level below top of casing: 120 (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 m,
( ) 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) 30 - • Method of test: 2 hours 24c.For Water Supply&Iniectiol Wells: In addition to sending the form to
the address(es) above, also subniitl 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. I
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Form GW-1 .. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016