GW1--01045_Well Construction - GW1_20240212

11-
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb ,14,WATER ZONES 'a -
Well Contractor Name FROM TO DESCRIPTION
0 ft• 305 ft• sg,
2418 305 ft• 485 ft. sew
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. 44 ft• 61/4 ' in. PVC
Company Name
J M Q-322W 16.INNER CASING OR TUBING(geothermal closed-loop) _ � _-
2.Well Construction Permit#: DIAMETER TO DIETER THICKNESS MATERIAL
' List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. 1 in•
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 11.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural DMunicipal/Public ft. ft. in.'
*Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
MI Industrial/Commercial DResidential Water Supply(shared)
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
•Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
'*Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*I Aquifer Test 0IStormwaterDrainage 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) D Other(explain under#21 Remarks) 0 ft. 44 ft• Clay f'
4.Date Well(s)Completed: 01/12/24 Well ID# 44 ft• 505 ft• Granite'`
ft. ft.
5a.Well Location:
Don Hamiel ft. ft.
•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
135 Tanglewood Ln. Clyde 28721 ft. ft. u `: �,�.,_,•�
Physical Address,City,and Zip
ft. ft. -� �e � �
,�
Haywood 8628-63-5406 tin:REMARKS 17 h-H.1-2.2Q24
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t'�.'!
(if well field,one 1at/long is sufficient) 22.Certification: '
35.564 N -82.946 Wbue:ii7/„... 01/12/24
6.Is(are)the well(s) Permanent or Temporary Sig ure of Certified Well Contractor Date
By signing this form,I hereby cert&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or QNo 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#11 remark,'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 INSTRUCTION S
9.Total well depth below land surface: 505 (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:
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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 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: j
(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) I 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: 92 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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