GW1--01518_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.1WATERZONES. 1, . , "
Well Contractor Name 'FROM TO DESCRIPTION
0 ft. 145 ft. iospm
4238
145 ft' 240 ft' 30 gp
NC Well Contractor Certification Number I5'OUTER CASING(lotinultr cased wells)OR LINERlif ap livable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 78 ft. 61/4 rn• PVC
Company Name .;16.INNER CASINGORTUBING( eethermal dosed-loop)
2.Well Construction Permit#: `�M 268 W 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 EiMunicipal/Public ft. ft. t
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. iii
Industrial/Commercial 'Residential Water Supply(shared)
Irrigation ::-1!7.:SCREENi, ";-"", -...,..7":.,.-:"=---." t;;;'-34,'2'„'"::'::,`L'-!.. -!,----:;',.--,-,:=W„:5.'"."..,.:!-,' ---,.:='.=-1,,t`,I'L':',:,,--
FROM TO I
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
wlMonitoring DRecovery _ ft. ft.
Injection Well: ft. ft.
®*Aquifer Recharge EIGroundwater Remediation
•:19.SAND/GRAM-PACK(if applicable) - - -,,
**Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IIAquifer Test ElStonnwater Drainage ft. ft.
vlExperimental Technology 0 Subsidence Control ft. ft.
I
11 Geothermal(Closed Loop) D Tracer w20.1)RILLINGLOG`(attachadditioi alsheets"ifnecessaiy)' _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
11 Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks)
0 ft. 78 rt. Clay
4.Date Well(s) 02/15/24 Completed: Well ID# 78 ft' 245 ft' Granite e
5a.Well Location: ft. ft. 1::::-7 L.,Ln L:
Vicky Cox/Linda Lane/Hill Pro Bldrs ft. ft. MAR (j LGL^
1 2 4
' Facility/Owner Name Facility ID#(if applicable) ft. ft.
88 Stormy Way Waynesville 28785 ft. ft. tnf;;r f;�%.r'.Fcil ?' ate;:;., li?;;
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Physical Address,City,and Zip ft. ft. `'+iK `){=
Haywood 8607-68-2403 121:11Emmucstx:. 4, . _ _ . .. 1 ..=,, . .. ;
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.Certification:
35.547 N -83.014 W
.-Je,e ' , 02/15/24
6.Is(are)the'well(s) Permanent or lTemporary Signature of Certified e 1 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: QIYes or jNo 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#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 ifdii different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (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 Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of thiis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1 '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 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: 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