GW1--01535_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robin Webb '14.WATERZONES - - -
FROM TO DESCRIPTION
Well Contractor Name p ft. 305 ft. so.
2418 305 ft• 405 ft' .saw,, 1
NC Well Contractor Certification Number 150-oUTER CASING(for-multi-cased•wells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 73 ft. 61/4 in. PVC
Company Name ,t
2023-24840-9-12875 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. UIC,County,State,Variance,etc.) R. ft. in.
3.Well Use(check well use): ft. tt.
in.
17.SCREEN:':• • .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural DMunicipal/Public ft. ft. in.
**Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft. ft. in.
®IIndustrial/Commercial DResidential Water Supply(shared) 18.-GROUT' ;- _ -. '
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonite
niMonitoring Recovery ft. ft.
Injection Well:
ft. ft.
NIAquifer Recharge DJ Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®[Aquifer Test DStormwater Drainage ft. ft.
*'Experimental Technology DSubsidence Control ft. ft.
*Geothermal(Closed Loop) OITracer ;20.DRILLING LOG.(attach additional sheets if necessary),'. -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
VI Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
p ft. 73 ft. Clay
4.Date Well(s)Completed: 12/26/23
Well ID# 73 ft 705 ft. Granitej'b?...— a L.i
5a.WellLocation: ft. ft. MAR 1 ? 2074
Karen Gerard ft. ft. MAR
Facility/Owner Name Facility ID#(if applicable) ft. ft. m i;I;fe r'.1 'r _^'nr N" 'r'
Lt.31C/325 Parkway Dr. Maggie Valley 28751 ft. ft.
Physical Address,City,and Zip
ft. ft.
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Jackson 7665-25-7441 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.Certification:
35.480 N -83.156 W QL '&
1i� O� 12/26/23
6.Is(are)the well(s) Permanent or JTemporary Signrc of Certified Well 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 X�i 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 in 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: 705 (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: 200 - (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.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 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: 127 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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