GW1--01044_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
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1.Well Contractor Information:
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Robin Webb 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft• 305 ft• t awn
2418
305 ft• 565 ft' 49
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 ; THICKNESS MATERIAL
0 ft. 25 ft. 61/4 I in' Rotary
Company Name
JMQ-293W 16:INNER CASING ORTUBING'(geothermalcliised-loop) :.
2.Well Construction Permit#: FROMTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.`SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1111iAgricultural JMunicipal/Public ft. ft. in., `
IIIGeothennal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.I '
*I IndustriallCommercial E3Residential Water Supply(shared)
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
®I Monitoring _J Recovery ft. ft.
Injection Well:
ft. ft.
XI Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III IAquifer Test DStonnwater Drainage ft. ft.
*Experimental Technology Ejll Subsidence Control ft. ft.
%I Geothermal(Closed Loop) OITracer :-20.DRILLING LOG(attach additional sheets if necessary)' ._ :-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
K Geothermal(Heating/Cooling Return) pother(explain under#21 Remarks) 0 ft. 25 ft- Clay
4.Date Well(s)Completed: 12/15/23 Well ID# 25 ft• 605 ft' Granite
ft. ft.
5a.Well Location: •
Joe & Denise Oliveri ft. ft. .
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1955 Winding Creek Rd. Waynesville 28786 ft. ft. 'tr;; I - ••
Physical Address,City,and Zip ft. ft. r[b 1 'A rl' i d
Haywoo 7685-65-6344 z1.REMARKS .
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ii,gor 'aaea Pres ej UII#
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.CeSti Ica on:
35.482 N -83.076 W
'IA./ (. 0. 12/15/23
6.Is(are)the well(s) Permanent 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: lJYes or Xi No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction 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: 605 (ft.) 24a. For All Wells: Submit thisl,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: I II
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
61/4 I,
11.Borehole diameter: (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
(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) 5 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: 109 tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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