GW1--01524_Well Construction - GW1_20240312

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
1
Robin Webb „14:WATER ZONES::' , t -
Well Contractor Name FROM TO DESCRIPTION
0 ft• 165 ft• isga,
2418
ft. ft.
NC Well Contractor Certification Number 15:OUTER'CASING:(for multi-casial wells)OR LINER'(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 80 fL 61/4 in' PVC
Company Name
WI22100102822 I6.IM4ER CASING OR TUBING( eothermal 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.
=17.SCREEN .,-
Water Supply Well: '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*'Agricultural DMunicipal/Public ft. ft. in.
m Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft, ili.
ViliIndustrial/Commercial DResidential Water Supply(shared) AS.GROUT `' ' ` -` .
®i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft• Bentonite
®'Monitoring EliRecovery ft. ft.
Injection Well:
ft. ft.
*'Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
fiAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®"Aquifer Test • 0 Stonnwater Drainage ft. ft.
"[Experimental Technology OISubsidence Control ft. ft. 1
®l Geothermal(Closed Loop) OTracer ,20.DRILLING LOG(attach additional sheets if necessary) "
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
a Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 80 ft. Clay
4.Date Well(s)Completed:02/13/24 Well ID# 80 ft. 185 ft' Granite `-, ! . :..�
I I:= �,%..0 '
5a.Well Location: ft. ft. 1 i F. $,.
William Nash ft. ft. MAR 12 2f124
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
It tt,,f ri tFrd ;1?::':::ix•=r7. i_;i?
131 Wyatt Andrew Dr. Mills River 28759 ft. ft.
DiAlr ThDr,
ft. ft.
Physical Address,City,and Zip
Henderson 9631-00-2380
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.Certi Ica ion:
35.374 N -82.589 W
)6 a. _Q- 02/13/24
6.Is(are)the well(s)�Permanent or Temporary Signature Certified Well Con ctor 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: DYes or X!No 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
i
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
6 1/4 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 15 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 io 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