GW1--01041_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
s Robin Webb ;14:WATER'ZONEs :,4 I '
FROM TO DESCRIPTION
Well Contractor Name
0 ft. 305 ft. +gpm
2418
305 ft. 445 ft' dam
NC Well Contractor Certification Number 15:OUTEILCASING(for=multi-ca'sedrwells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER! THICKNESS MATERIAL _
0 ft. 89 ft• 61/4 i in' Rotary
Company Name
J M Q-321 W 16.INNER CASING OR TUBING`(geothernial.closed-loop)r =
2.Well Construction Permit#: FROMTO 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: 17::SCREEN : .'
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.I
DGeothermal(Heating/Cooling Supply) X!Residential Water Supply(single) ft. ft. in.!
9 IndustriallCommercial DResidential Water Supply(shared) 18.=GROUT y r_;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite
Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19'SAND/GRAVEL PACK"(if applicable) - ""
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStonnwater Drainage ft. ft.
Experimental Technology
1Subsidence Control ft. ft.
Geothermal(Closed Loop) (Tracer ,20.':DRILLING LOG:(attach additional'sheets if necessary) - ` ''- , :.
FROM TO DESCRIPTION(color,hardness,soil rock type,grain sire,etc.)
I Geothermal(Heating/Cooling Return) 173 Other(explain under#21 Remarks) 0 ft. S9 ft. Clay
4.Date Well(s)Completed: 12/20/23 Well ID# 89 ft' 465 ft' Granite
ft. ft. (,
5a.Well Location:
Stewart Hooper ft. ft. i kC� �1 ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
341 Orion Davis Rd.Waynesville 28786
ft. ft. Irdi 22024
Physical Address,City,and Zip ft. ft. init?rmw4ieD Pr x n,. u+
Haywood 7694-35-2560 .21:REMARKS:_ ._ _ _ .1AV.116 UEtt . ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one ladlong is sufficient) 22.Cer'G tion•
35.456 N -83.054 W i 1 12/20/23
6.Is(are)the well(s)®(Permanent or Temporary Signature o 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: JIYes or ONo 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: 465 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (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: 1
(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
1
13a.Yield(gpm) 30 Method of test: 2 hours 24c.For-Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subniit1one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 85 tabs completion of well construction to +}he county health department of the county
where constructed. fI
I'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016