GW1--08035_Well Construction - GW1_20231214

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 .
Robin Webb 14.WATER R ZONES -
Well Contractor Name FROM TO DESCRIPTION
0 ft. 405 ft. ,,,,
2418
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 97 ft. 61/4 in. PVC
Company Name —
JMQ-297W 16.INNER CASING OR TUBING(geothermal closed-làop) -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: • ',17.SCREEN
FR_OM_ TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
Agricultural jMunicipal/Public ft. ft. in.
I '
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
•
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) D Other(explain under#21 Remarks) o ft. 97 ft. Clay
4.Date Well(s)Completed: 11/03/23 Well ID# g7 ft. 425 ft.
p Granite
5a.Well Location: ft. ft. 4-., _ - ,
Kyle Chandler ft. ft. ..—"•,..-,'it--i V Q.,-..1
Facility/Owner Name Facility ID#(if applicable) ft. ft. DEC 1 /, 2023
188 Toronto Trail Clyde 28721 ft. ft.
,:r
Physical Address,City,and Zip ft. ft. Di:,y;Cy' a.
Haywood 8648-93-7363 21.REMARKS -
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.C ' cation: '
35.565 N -82.869 W -
t_itrici5.,
11/03/23
6.Is(are)the well(s)0Permanent or OTemporary Signatur of Certified well Contractor Date
By signing this form,I hereby certify that the u•ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes or DINo 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: 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@100') construction to the following: I
10.Static water level below top of casing: 50 (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
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,IUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3° Method of test: 2 hours 24c.For Water Supply&Injection 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 io the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016