GW1--01035_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Robin Webb .14:.wATER zoNEs, . . ., x5 .
Well Contractor Name FROM TO DESCRIPTION
0 ft. 125 ft. 1m9Pm '
2418 {
125 ft' 605 ft• gpm 1
NC Well Contractor Certification Number 15:OUTER.CASING(for"niultt,cased wells)ORLINER'(if ap iicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 38 ft. 6 1/4 I ' to PVC
Company Name
2023-25843-9-13340 r,16:INNERCASINGORTUBING:(0eotheruiakclosed400p) _ _
2.Well Construction Permit#: FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. I : in.
3.Well Use(check well use): ft. ft. in.
17.'SCREEN_, .."i =, r.' ' ?x 7 !''
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. •. _.. ?L i
t ;
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) -
18.`GROUT t :1
Irrigation FROM TO . c MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• zo ft. Bentonite:
[3Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
BAquifer Recharge 0 Groundwater Remediation '
19:SAND/GRAVEL PACK(if applicable).-:--
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test DStorinwater Drainage ft. ft.
®!Experimental Technology ID Subsidence Control ft. ft.
*Geothermal(Closed Loop) OTracer . ;20.DRILLING LOG.(attach additiaiial'sheetsif necessargj` . ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
®Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) o ft. 38 ft• Clay
4.Date Well(s)Completed: 01/03/24 Well ID# 38 ft' 805 ft.
PGranite
5a.Well Location: ft, ft. i
Scott Dubs ft. ft. (:.C.,C.V i::►, C Li
Facility/Owner Name Facility ID/1(if applicable) ft, ft,
Hens Nest Trail MaggieValley 28751 ft. ft. I-t!� 2 20Z4
Physical Address,City,and Zip • ft. ft. i tl(Grre.v.ten
- - -- ..
»-{ tG= a
k^
Jackson 7665-63-5750 z21,,REMARicsa;€ - - � . , -0
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:
35.475 N -83.143 �, „ G
.�A NAWtlfr01/03/24
6.Is(are)the well(s)®!Permanent or Temporary Si ature of Certified Well Contractor 1 Date
By signing this form,I hereby certibi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or ISA 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#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 805 (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: j.
10.Static water level below top of casing:403 (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. P
( ) 24b.For Injection Wells: In addition to sending the form to the address in 24a
"Rotary -above,also submit-one-copy of his form within 30-days of completion of well12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,3Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test: 2 hours 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also HTH 147 tabs submit'one copy of this form within 30 days of
'
13b.Disinfection type: Amount: completion of well-construction o the;county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016