GW1--01517_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Travis Greene =14.WATERZONEs 't•'" _ ` '_ t .' '--,
FROM TO DESCRIPTION
__
Well Contractor Name p ft• 300 t[. 50 gpm
4238
ft Ys::ouT .
ft. ft.
NC Well Contractor Certification Number CASING(for multi=cased-wells)OR LINER(if ap licable) =
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 121 ft• 61/4 i in. PVC
Company Name
MCM-32.7W =I6:SINNERCASINGOR TUBING(geothermalclosed=Coop) a - _ _>
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: s '17.SCREEN - .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
II Agricultural i_.I Municipal/Public ft. ft. in.
WI Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
$1Industrial/Commercial Residential Water Supply(shared) i
1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Bentonite
*Monitoring ORecovery ft. ft. .
Injection Well: ft. ft.
®*Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if-applicable)
*Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test D Stonnwater Drainage ft. ft.
*Experimental Technology D Subsidence Control ft. ft.
*Geothermal(Closed Loop) 0ITracer .`20.rDRILLING LOG(attach additional-sheets if necessary) - -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
VI Geothermal(Heating/Cooling Return) EtOther(explain under#21 Remarks)
0 ft. 121 ft• Clay
4.Date Well(s)Completed: 02/08/24 Well ID# 121 ft• 325 ft• Granite!
5a.Well Location: ft. ft.
Travis Thompson ft. ft. : ,.,,,.LLa ' 3
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAN 2021
Chestnut Mountain Rd. Canton 28716 • ft. ft. '\
Physical Address,City,and Zip .ft. ft. trifc,•cr,i:1 ?r: ';h�'c rg 1-!"'
Haywood 8666-59-4866 -.21.;REMARKS :.` D..t Jw
•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35.531 N -82.814 �, ) .
t , ., 1��4 `2 02/08/24
6.Is(are)the well(s)JPermanent or Temporary Signature of Certifie, ell Contractor Date
By signing this form,I hereby cert that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DIYes or Xi,No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction h formation 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: 325 (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@I00') construction to the following:
10.Static water level below top of casing: 100 (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: I
(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) 50 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: 60 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