GW1--01039_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ! ,
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1.Well Contractor Information:
Robin Webb
"i14.WATER ZONES u.,'.'1 .', ., ,
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 325 ft. iao9om
2418
ft. ft.
NC Well Contractor Certification Number 45.OUTER CASING(for-multi-cased';yells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 62 ft' 61/4 ' in. PVC
Company Name
J C H-043W '16.INNER CASING OR TUBING`(geothermal•closed'-loop)-
Z.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: i7.SCREEN ;'.
FROM TO DIAMETER SLOT. SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
1 Geothermal(Heating/Cooling Supply) iXl Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT r '''
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
aIAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) •
NI Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
**Aquifer Test QStonnwater Drainage ft. ft.
11 Experimental Technology QSubsidence Control ft. ft.
"Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary). `
It Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROMO it• T6 ft. CEa DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
2 Y ;
4.Date Well(s)Completed: 01/19/24 Well ID# 62 ft 345 it.
Granite
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5a.Well Location: ft. ft.
Britt Chastain/Michael Huskey \�j...
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
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55 Feather Ln. Waynesville 28786 ft. ft.
ft. ft. tn�t:iIV',:rilt'il tJrrrf
Physical Address,City,and Zip �W � Drt:q�J
21.REMARKS .: -
Haywood 8645-08-5152 • . -
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert i tion: 1
35.495 N -82.896 W
IQ, EP^ l-
01/19/24
6.Is(are)the wells) iXj Permanent or DITemporary Signatur of Certified Well Contractor Date
By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or X!No with 1SA 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 raider#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: 345 (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: 160 (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 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'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 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: 63 tabs completion of well construction ltol the county health department of the county
where constructed. 1 ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016