GW1--08032_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene ,14.WATER ZONES, . , { '
Well Contractor Name " FROM TO DESCRIPTION
0 ft. 300 ft. as up. I O I
4238
ft. ft.
NC Well Contractor Certification Number
"15:OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER! THICKNESS MATERIAL
Company Name p 0 ft• 92, ft. 61/4 G 1ln• PVC
OSS-2023-0886 _16.INNER CASING OR TUBING(geothermal closed-loop)'- "`" ., .,
2.Well Construction Permit#: OSS-2023-0886 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC Counq;State,Variance,etc.) ft. ft. ,in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: :,17.SCREEN . .
FRO ,.M TO DIAMETER.• SLOT SIZE THICKNESS MATERIAL
,Agricultural DMunicipal/Public ft. ft. in.!, ,
t
NI Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft• ft. in•j i
$l Industrial/Commercial QResidential Water Supply(shared) °18:GROUT. - . :." ,
'_ 'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft- Bentonite
III Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
®(Aquifer Storage and Recovery 0Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
ilIAquifer Test DIStormwater Drainage ft. . ft. I;
&Experimental Technology EtSubsidence Control ft. ft. I�,
®(Geothermal(Closed Loop) , f Tracer .20.DRILLING LOG(attach additional sheets if necessary) -
ill Geothermal(Heating/Cooling Return) • f Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft• 92 ft. Clay
4.Date Well(s)Completed: 11/09/23 Well ID# 92 ft• 445 ft.
Granite
ft. ft.
5a.Well Location: 7 s x-,--1
David McCraw ft. ft. I ' 1 L
Facility/Owner Name Facility ID#(if applicable) ft. ft. DEC 1 /. TJe3
1591 Airport Rd. Flat Rock"28731 ft. • ft. l fl`r;�^;' '
• .,,-p,: - rJE.i
Physical Address,City,and Zip ft. ft. DIA v .; y y
Henderson REID: 105327 -''2L REMARKS•
County Parcel Identification No.(PIN)
- p .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(if well field,one lat/long is sufficient) 22.Certification:
35.315 N -82.424 W
,�,, �. _ 11/09/23
6.Is(are)the well(s)JPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes 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 j
9.Total well depth below land surface: 445 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dlgerent(example-3@200'and 2@100) construction to the following:
i
10.Static water level below top of casing:20 (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 Infection 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) 2.5 Method of test: 2 hours 24c.For Water Supply&Iniectiol 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: 61 tabs completion of well construction to the county health department of the county
- where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016