GW1--02058_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
'Travis Greene 14:WATERZONE
We1lContractorName FROM TO DESCRIPTION
0 ft. 100 ft. senor
4238
100 ft. 185 ft. 70
NC Well Contractor Certification Number ;15:.OUTERCASING(foranultt-casedwells).ORLINER(if applicable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. go ft. 61/4 tn• PVC
Company Name
•16.=1NNER CASING OR TUBING'(geotlierrnal°closed-loop)': -'- .
2.Well Construction Permit#: DCH-012W 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.
,17.-SCREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural EjMunicipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) ;Residential Water Supply(single) ft. ft. in.
*Industrial/Commercial E3Residential Water Supply(shared) .:18:GROUT ,
®I Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 10 ft• Bentonite
III Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge EjGroundwater Remediation a9:SAND/GRAVEL.PACIC(if applicable)...'
*Aquifer Storage and Recovery EjSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test QlStonnwater Drainage ft. ft.
*Experimental Technology DSubsidence Control ft. ft.
HiGeothermal(Closed Loop) QTracer -3`20.1)RILLINGL:OG`(attachadditional-sheets`ifnecessary) . "`
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft.
90 ft. Clay
4.Date Well(s)Completed: 03/26/24 Well ID# 90 ft. 305 ft.
Granite
5a.Well Location: ft. ft.
Peter&Jeanne Morris t:_,,i._ ;; a, a 7
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lot 31 Raccoon Point Canton 27816
ft. ft. al'" v 5 2024
Physical Address,City,and Zip ft. ft. In:.r;r.r•.0? P"_,-;:,5 ,c;(;;;1
Haywood 8678-46-0662 3,21:1REMARKS,4= ., •. ' , ' -
County Parcel Identification No.(PIN) Installed 95'4"liner due to not being able to achieve
20'of bentonite to grout around well casing.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.577 N -82.787 W,
in. i a) O � 03/26/24
6.Is(are)the well(s)'Permanent or Temporary Si nature of Certified ell ontmctor 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: IjYes or No with 15A NCAC 02C.0100 or ISA 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: 305 (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: 80 (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.) 246.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) 12 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: 56 tabs completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016