GW1--00867_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Travis Greene 14.WATERZONES: .; ,
Well Contractor Name FROM TO DESCRIPTION
0 ft. 200 ft. 17gprn '
4238 •
ft. ft.
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. 67 ft. 6 1/4 I. 'in. PVC
Company Name 1
OSS-2022-0208 „FROM TO UBING(geothermal closed-loop)
16..INNER CASING'OR T
2.Well Construction Permit#: 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
it Agricultural DMunicipal/Public ft. ft. in.
it Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in
*I Industrial/Commercial DResidential Water Supply(shared) ,18-GROUT :`' '
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentnite
21lMonitoring DRecovery ft. ft.
Injection Well:
ft. ft.
ali Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
%Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test OStormwater Drainage ft. ft.
a Experimental Technology D Subsidence Control ft. ft.
i
*Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessaryj' :' -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
I®Geothermal(Heating/Cooling Return) D Other(explain under#21 Remarks) 0 ft. 67 ft. Clay ! i
4.Date Well(s)Completed: 10/27/23 Well ID# 67 ft• 225 ft' Granite'
ft. ft.
5a.Well Location:
Thomas Riley ft. ft. _,
Facility/Owner Name Facility ID#(if applicable) ft. ft. t '' H.- @ ! . a
1116 Etowah School Rd. Hendersonville 28739 ft. ft. F E 13 0 r 7074
Physical Address,City,and Zip ft. ft.
Henderson 9538-03-8431 21.REMARKS '-;-.- ln..r� l -K. 5..'.J—'
Delvk,i Utom
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.Certification:
35.300 N -82.584 W // 10/27/23
6.Is(are)the well(s))x'Permanent or Temporary Sign Mule of Certified Well Contractor Date
By signing this form,I hereby certify dial the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XD'No 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 it formation 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:I SUBMITTAL INSTRUCTIONS ,
depth below land surface: 225
9.Total well
(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: 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.) 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) 17 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: 40 tabs completion of well construction to,the county health department of the county
i where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources : Revised 2-22-2016