GW1--01043_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Robin Webb 14.WATER ZONES ' ^ ;..: ,
Well Contractor Name FROM TO . DESCRIPTION
0 ft. 225 ft• irswm
2418
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.(for.multi-cased'vells)ORZINER(if applicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER I- THICKNESS MATERIAL
0 ft. B5 ft' 6 1/4 in. l Steel
Company Name
D C H-0I 51N ,16 INNER CASING OR TUBING(geirthernial 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 TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in. ;
Geothermal(Heating/Cooling Supply) `Residential Water Supply(single) ft. ft. in. i
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT "_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 65 ft* Clay
4.Date Well(s)Completed: 01/23/24 Well ID# 65 ft• 245 ft' Granite f
5a.Well Location: ft. ft. :„T ''
Courtney Scott. ft. ft. ti`- Ll� i
j V t,
ft. ft. L
Facility/Owner Name Facility ID#(if applicable) fr tt3 i 2 2roil
21 Dusk Dr.Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft. It-gv"ram£D1?a r'� RI URii'
Haywood 8645-01-9521 21:12EMARKS ,,`, ',
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.Certi 'on:
35.477 N -82.894 W _
( 9. 01/23/24
6.Is(are)the well(s) Permanent or Temporary Signature ertificd Well Contractor Date
ix.
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!mown well construction information and explain the nature of the copy of?his 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: 245 (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: j
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--Injection Wells: 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 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: 43 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016