GW1--08036_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Robin Webb 14.WATER ZONES
Well Contractor Name • FROM TO DESCRIPTION
2418 o ft. 85 ft. 40gprn I
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi c'sed.wel►syOR LINER(if ap licable) ." .
Greene Brothers Well & Pump, WT Inc. - FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 57 ft. 61/4. in• PVC
Company Name
M lrlVlil-�A '16.INNER CASING OR TUBING(geothermal closed-loop) `
2.Well Construction Permit#:
F 04M tt t V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
• Water Supply Well: "•17.SCREEN '
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. ft. lin!
Geothermal(Heating/Cooling Supply) ;X Residential Water Supply(single) ft. ft. fin,
,Industrial/Commercial E3Residential Water Supply(shared) �'
18.GROUT -
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
Monitoring E3Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) ' -
Aquifer Storage and Recovery _ 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft. i .
Geothermal(Closed Loop) OITracer 20.DRILLING LOG(attach additional sheets if necessary) -
- FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
Geothermal(Heating/Cooling Return) 173 Other(explain under#21 Remarks) 0 ft. 57 ft. Clay
4.Date Well(s)Completed: 10/27/23 Well ID# 57 ft* 105 ft Granit
l5a.Well Location: ft. ft. `� °w'i.. : lV •^^ .,1
Christine Surrett/Jerry Mehaffey ft. ft. DEC 1 / 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Inr^r+
•
157 Martin Rd. Canton 28716 ft. ft. ^r;,
y
Physical Address,City,and Zip
ft. ft. i
Haywood 8645-44-8127 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 fication:
35.485 -82.881 N �,
(.710/27/23
6.Is(are)the well(s)JPermanent or []Temporary igna re of Certified Well Contractor Date
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: £Yes or ONo 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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below topof casing:30
(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 Iniection-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,lynderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: 2 hours - 24c.For Water Supply&Injectiion 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: 18 tabs .completion'of well construction to the county health department of the county
where constructed. I. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016