GW1--01036_Well Construction - GW1_20240212

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 1A:WATER;ZONES '
Well Contractor Name FROM TO DESCRIPTION
0 ft. 140 ft. 39om I
4238 I I . ---
ft. ft.
NC Well Contractor Certification Number "-15.OUTER CASING(for lMulti-cased'.wells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 82 ft. 61/4 I in. PVC
Company Name
,16.INNER CASING OR TUBING(geothermal closed-loop)•
2.Well Construction Permit#: OSS-2022-0683 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.
Water Supply Well:
FROM TO DIAMETER i 'SLOT SIZE THICKNESS MATERIAL
'Agricultural OMunicipal/Public ft. ft. in.I
l®I Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in. ''
MitIndustrial/Commercial DResidential Water Supply(shared) 18.:GROUT= >
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
®iMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
%IAquifer Recharge 0Groundwater Remediation
.-19.SAND/GRAVEL PACK(if applicable)
%iAquifer Storage and Recovery ilI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IIII Aquifer Test DStornwaterDrainage ft. ft. •
*Experimental Technology Ell Subsidence Control ft. ft.
%Geothermal(Closed Loop) OITracer -,20.;DRILLING LOG(attach additional sheets if necessary) ' , . , ..
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
$Geothermal(Heating/Cooling Return) 010ther(explain under#21 Remarks)
0 ft. 82 ft. Clay
4.Date Well(s)Completed: 01/04/24 Well ID# 82 ft. 325 ft.
p Granite
ft. ft.
5a.Well Location: T.�4. '',,-....--CZ
^_'I a r-•
Lauren Stepp&Ashley Espey/Brandon Vinez ft. ft. 'L. t. !% .r
Facility/Owner Name Facility ID#(if applicable) ft. ft. , , ' t�t t1 O,�
277 Williamson Rd. Mills River 28759 ft. ft. U 4
I+
ft. ft. rr4..�1Ir.4F
Physical Address,City,and Zip D�tt/!1!{,,,54111��r�t�1{� ,.,,•^y WO
Henderson 9631-07-0575 21.REMARKS _.
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: E
35.393 N -82.590 W
01/04/24
-,., 4._-__ ,
6.Is(are)the well(s)JPermanent or Temporary Signature of CertifiContractor Date
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: IYes or tNo 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: 325 (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: (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 Infection 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 i ei ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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: 60 tabs completion of well construction to ithe 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
I