GW1--01042_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information: I ,
i
Robin Webb '.14.WATER ZONES -i
Well Contractor Name FROM TO DESCRIPTION
0 it 205 ft. 19pm I 1
2418
205 ft• 285 ft" Itpm
NC Well Contractor Certification Number '15:OUTERCASING(fornialti-cased wells)+OR LINER(if ap licable) -
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 56 ft. 61/4 I' in' PVC
DGS-078W -16 INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: .1J 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: 17,:SCREEN ,, i,
FROM TO DIAMETER 1, SLOT SIZE THICKNESS MATERIAL
it Agricultural DMunicipal/Public ft. ft. in.1'
*Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) ft. f. in.i-
(
*IIndustrial/Commercial DResidential Water Supply(shared)
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft' Bentonite
11IMonitoring ORecovery ft. ft.
Injection Well:
ft. . ft.
it Aquifer Recharge D Groundwater Remediati on
19.SAND/GRAVEL PACK(if applicable)
i1Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
It Aquifer Test t jStonnwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
It Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary).
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
IN Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 56 ft Clay
4.Date Well(s) 01/05/24
Completed: Well ID# 56 ft- 305 ft' Granite i '� ,P. t'"''ii77 ...
5a.Well Location: ft. ft. I ''� I� .p c'.��
Peter Succo ft. ft. r t8 1 2 104
Facility/Owner Name Facility ID#(if applicable) ft. ft.
381 Upwardft. ft.Way Waynesville 28785 hiti�rirz � "Dit. t'd'tJl il?
ft. ft.
Physical Address,City,and Zip
Haywood 7698-99-8965 '21 REMARKS' a..
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.C rtifica on:
35.578 N -83.036 W •
r e`)4
7 01/05/24
6.Is(are)the well(s)0Permanent or Temporary Signature £Certified ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo with 15A NCAC 02C.0100 or 1SA 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 if different(example-3@200'and 2@100') construction to the following: 1
10.Static water level below to of casin 50
p g: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cien,ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 _ in, i
( ) 24b.For-Injection;'bells: In•addititm 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(enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: 2 hours 24c.For Water Supply&Infection 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 to 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