GW1--01040_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14:WATER1ONES `' :
FROM TO DESCRIPTION
Well Contractor Name
N/A ft- N/A ft- NIA I 1
4238 ft. ft. I I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased`wells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 49 ft. 61/4 i in. Steel
Company Name
J M Q-318W 16.INNER CASING ORTUBING:(geothermal closed-Ioop)'r '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(7.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO .DIAMETER' SLOT SIZE THICKNESS MATERIAL
®*Agricultural Municipal/Public ft. ft. in.h
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.I
I
•Industrial/Commercial X®LResidential Water Supply(shared)
18.GROUT' ,.
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Bentonite
111 I Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
0,Aquifer Recharge U Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
It Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test DStonnwater Drainage
ft. ft.
•Experimental Technology Subsidence Control ft. ft.
NI Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach;additional sheets if necessary) .
*Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 49 ft. Clay
4.Date Well(s)Completed: 12/26/23 Well ID# 49 ft. 445 ft' Granite
ft. ft. ( �';:..7.*;""".
'^'•.;"-4 r►-
5a.Well Location: ;,1 't i.1�e t cam'+
Wanda Arrington ft. . ft.
ft. ft. . I-tti / 2 2024
Facility/Owner Name Facility ID//(if applicable) '
122 Chinquapin Rd. Canton 28716 ft. ft. intorrnr.izien P,r^ cAp
up,
Physical Address,City,and Zip
ft. ft. DWO y
Haywood 8662-59-3069 21.REMARKS'.; a 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: I
35.418 N -82.809 W 0
C��i.P>.r.� ' ,4! 12/26/23
6.Is(are)the wells)JPermanent or Temporary Signature of Certified Well Contractor 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: DYes or X',No 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: 445 (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: N/A (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
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service"Center,Raleigh,NC 27699-1636
13a.Yield(gpm) N/A Method of test: 2 hours 24c.For Water Supply&Inje Ition 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: 81 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016