GW1--01037_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I ;
1 I
Travis Greene 14.WATERZONES' - ',;h •?•
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 140 ft. x„,
4238 140 ft• 280 ft• ssspm
NC Well Contractor Certification Number 15:OUTER CASING(for ñulti-cásed wells)OR LINER(if licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETERI THICKNESS MATERIAL
0 ft. 84 ft. 61/4 I in. PVC
Company Name t
OSS-2023-1 785 -16.INNER CASING OR TUBING closed-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.
Water Supply Well: FROM E TO I DIAMETER SLOT SIZE TIHCICNESS MATERIAL,
Agricultural DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. inf '
IndustriallCommercial DResidential Water Supply(shared) 1i3:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
� 19.SAND/GRAVEL PACK(if applicable) - "
l -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
ft. ft. 1
Experimental Technology 0ISubsidence Control ft. ft.
Geothermal(Closed Loop) 0ITracer 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• ' 84 ft• Clay I`
4.Date Well(s) 01/08/24 ft. ft.Completed: Well ID# 84 305 Granite ',y'".• ,,.,,„T
5a.Well Location:
ft, ft. i *+-L CgVt[)
Cottages at Byron Forest ft. ft. i ' F t H 1 2 2Q2T
Facility/Owner Name Facility ID#(if applicable) ft. ft. j
88 Byron Forest Dr. Mills River 28759 ft. ft. triifirirrei Psr„-
ft. ft.
Physical Address,City,and Zip
Henderson 9630-70-6857 zL'REMARKS .z
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:
35.346 N -82.562 `lt
01/08/24
6.Is(are)the well(s) Permanent or [ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or ONo with I5A 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths I d(erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (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.) I '
I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 8'5 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: 56 Tabs completion of well construction!td the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcest Revised 2-22-2016