GW1--00892_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Travis Greene 14:WATERZONES . ''
Well Contractor Name FROM TO DESCRIPTION
0 ft. 240 fL up.
4238
ft. ft.
NC Well Contractor Certification Number ':15:'OUTER CASING.(for:niulti cased'wells)OR LINER(if ap licable)' '
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 132 ft. 61/4 I in. PVC
Company Name
�16 INNER CASING ORTUBING.(geotherriial closed-loop)k.
2.Well Construction Permit#: WEL2023-00403 FROM TO DIAMETER 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.
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Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial
Irrigation Supply Well:
DResidential Water Supply(shared)
18._GRO.UT " _ .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water0 ft. 20 ft. Bentonite
Monitoring
Rccovery ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test
Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'(attach'additional'sheets if necessary), ''
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
'.Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
0 ft• 132 ft. Clay
4.Date Well(s)Completed: 11/16/23 ft. ft.Well ID# 132 265 Granite
5a.Well Location: ft. ft. t • ,----
Jerry Golden ft. ft. ,1 �w,F•„ , �';`�-
ft. ft. ' F• .�-.,4.
Facility/Owner Name Facility ID#(if applicable) F r G r
142 Mitchell View Rd. Swannanoa 28778 ft. ft. U 1) 2024
Physical Address,City,and Zip ft. ft. d'I' I""-':n?r:•,, tom . x
Buncombe 9689-22-8713 '21.'REMARKS , :'�' , °E y, y 1 ��� -
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:
35.605 N -82.422 W
11/16/23
j .ate ,et-) .�.....-4-
lls)JPermanent or Temporary Signature of Certified Well Contractor Date
6.Is(are)the we
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or jNo 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 in 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 ,
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this forim within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 120 (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 Zito 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: k
(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) 13 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: 47 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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