GW1--00866_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb v14.WATER ZONES i .',s - ,
We1lContrac[orName FROM TO DESCRIPTION
0 ft. 485 ft• lOgpm I '
2418
• ft. ft. I •
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased-.wells)OR LINER'(if ap licable)- --
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 50 ft. 61/4 I , in. PVC
Company Name
2023-25241-9-13093 ';',16.INNER CASING OR TUBING(geothermal closed-loop) := -
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.
17.SCREEN .,;:
Water Supply Well: s
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
ill Agricultural 0Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft, m•
$i Industrial/Commercial DResidential Water Supply(shared) .'.1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • o ft• 20 ft. Bentonite
*1Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
®I Aquifer Recharge 0Groundwater Remediation ;:19 SAND/GRAVEL PACK(if applicable) - ' -
*Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
®I Aquifer Test 0Stonnwater Drainage ft. ft.
*Experimental Technology D Subsidence Control ft. ft.
*Geothermal(Closed Loop) OTracer .-20.DRILLING LOG-(attach ailditidn al sheets if necessary)', ''• " `-.'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
',Geothermal(Heating/Cooling Return) QI Other(explain under#21 Remarks) 0 ft. 50 ft. Clay
4.Date Well(s)Completed: 11/15/23 Well ID# so ft• 505 ft• granite,
ft. ft.
5a.Well Location:
James Snyder ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. r- ?7----:1889 Woodfin Rd. Sylva 28779 ft. ft. `' T= `I " ` ` "
Physical Address,City,and Zip ft. ft. 1- D ZU L4
Jackson 7674-62-6470 a 2i.REMARKS
County Parcel Identification No.(PIN) ''1'`f•,_? `.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22. tiff lion• I
35.445 N -83.108 w
LA 11/15/23
6.Is(are)the well(s) Permanent or lTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certh'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 421 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 piovide 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: 505 (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:
10.Static water level below top of casing: 60 (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.) l 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
1
13a.Yield(gpm) 10 Method of test: 2 hours 24c.For Water Supply&Infection 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: 92 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016