GW1--01523_Well Construction - GW1_20240312

1 C -
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Robin Webb 14.WATER ZONES.
Well Contractor Name FROM TO _ DESCRIPTION
0 ft- 165 fL 12o n 1
2418 It. ft. i
NC Well Contractor Certification Number 15:°OUTER CASING(for inulti-cased wells)OR LINER(if applicable) -
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 48 ft. 6 1/4 ' in' I PVC
Company Name
OSS-2023-1657 16.INNER CASING OR TUBING(geothermal'closed-loop) -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIG County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN' ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OMunicipal/Public ft. ft. inl
111 Geothermal(Heating/Cooling Supply) Xi Residential Water Supply(single) ft. ft. in! - ,
®*Industrial/Commercial 0Residential Water Supply(shared) ' '
18.GROUT �,..- '
' (Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
stMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
*Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL.PACK(if applicable)
ill Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*,Aquifer Test 9Stormwater Drainage ft. ft.
®'Experimental Technology D Subsidence Control ft. ft. ,
®,Geothermal(Closed Loop) OITracer ;20.'DRILLINGLOG(attach additional sheets if necessary) `
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
III (Heating/Cooling Return) Di (explain under#21 Remarks)
0 ft. 48 ft. Clay I
4.Date Well(s)Completed: 02/19/24 Well ID# 48 -"
ft• 185 ft' Granite "'°\ f" Q.'i
ft. ft. ^'%l 4,..0 L..t, 1yd .,-.3
5a.Well Location:
Brian Kirk/Moore & Son ft. ft. MAR i r 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
159 Byron Forest Ln. Mills River 28759 .-�. ',ISFi
Physical Address,City,and Zip ft. ft.
Henderson REID 10011090 21,REMARKS
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. tifie lion:
35.348 N -82.563 W
-/T l W , 02/19/24
6.Is(are)the well(s) !�IX'Permanent or 'Temporary Signatur of Certified Well ontractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: '..i Yes or EjNo with 15ANCAC 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: 185 (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:
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 Infection 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.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) 1 0 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: 33 tabs completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016