GW1--00868_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene ,14.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 250 ft. 5gpm I I
4238 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased."wells)ORT7NER(if bcable)
Greene Brothers Well &Pump, WT_Inc. FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 78 ft. 61/4 in. PVC
Company Name
OSS-2022-0258 16.INNER'CASINGOR TUBING:(geothermalclosed-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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public
Municipal/Public ft. ft. in:
i
I Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. Jul
I
Industrial/Commercial Residential Water Supply(shared) ;;18.:GROUT
Irrigation FROM
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL,PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. i;
Geothermal(Closed Loop) OTracer 20.DRILLING_LOG(attach.additional.sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
1 Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) o ft. 78 ft. Clay
4.Date Well(s)Completed: 11/15/23 Well ID# 78 ft• 405 ft Granite
ft. ft. 1
5a.Well Location: ---
Ben Walker ft. ft. IT- i.."t,,.,•^FL -r 1.e 1.p 1
Facility/Owner Name Facility ID#(if applicable) ft. ft. 5
926 Hudgins Rd. Hendersonville 28792 ft. ft. r1—G eG2�r
Physical Address,City,and Zip ft. ft. I Ert�r _,C1 L. z.,'..2 OF i
Henderson 10004987 , '"'`,i
=21,:REMARKS;. - v -
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.442 N -82.332 �, 11/15/23
� �
6.Is(are)the well(s))Permanent or fiTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert j that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or Xj 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 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: 405 (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: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicejCenter,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: 1
(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) 5 Method of test: 2 hours 24c.For Water Supply&Iniel tion Wells: In addition to sending the form to
the address(es) above, also sulimit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 74 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 Revised 2-22-2016
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