GW1--08030_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Travis Greene 14.WATER ZONES... - _ - .
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft. 320 ft. 20 gp,,,
ft. ft. 1 l
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
Greene Brothers Well& Pump, WT Inc. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 24 ft, 61/4 I I in. I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSS-ZOZ3-�O69 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,.Variance,etc.) ft. ft. ht.
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
%Agricultural JMunicipal/Public ft. ft. in.
I'
ill Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. hi.
NI Industrial/Commercial DResidential Water Supply(shared) •
18.GROUT '
, I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o it 20 ft. Bentonite
%Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
*Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK(if applicable) - '
®I Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0 Stormwater Drainage ft. ft. I
NI Experimental Technology ; Subsidence Control ft. ft. 1
NI Geothermal(Closed Loop) Tracer 20 DRILLING LOG(attach additional sheets if necessary) " .. .. •-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
fit Geothermal(Heating/Cooling Return) 01Other(explain under#21 Remarks)
0 ft. 24 ft. Clay
4.Date Well(s)Completed: 10/26/23 Well ID# 24 ft. 345 ft. Granite
5a.Well Location: ft ft. l ( " �- _ a
Margaret Carpender ft. rc. i w''�.-'— tr
Y
Facility/Owner Name Facility ID#(if applicable) ft. ft. D F C 1 /•. 2023
358 Braewood Dr. Flat Rock 28731 ft. ft. '
. In,'r ..--. "i_,
f .7
t. ft. R:'•
Physical Address,City,and Zip D v QY�°t");11,,?J i
Henderson 9577-50-2349 ;:21._REMARKS
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) I
22.Certification: j
35.268 N -82.433 W 10/26/23
0,Lcccs�r/ , s-� r. r
6.Is(are)the well(s)JPermanent or %Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or QNo 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: 345 (ft-) 24a. For All Wells: Submit this Sorm within 30 days of completion of well
For multiple wells list all depths if d erent(example-3@200'and 2@100') ' construction to the following: I
10.Static water level below to 60
P of casin g� (fL) 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 24 •
c.For Water Supply&Injec lion 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: 63 tabs completion of well construction!to the county health department of the county
where constructed. I
,
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016