GW1--02063_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14:WATERZONEs '. ',
Well Contractor Name FROM TO DESCRIPTION
0 ft. 165 ft. m I
2418
ft. ft.
NC Well Contractor Certification Number -IS.OUTER CASING(for multi-casetiwells),OR;LINER.(if'ap licable) '
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 105 ft. 6 1/4 in' Steel
Company Name
J C H-07.7 W .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.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE TIICKNESS MATERIAL
111IAgricultural QMunicipal/Public ft. ft. in:
al Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) ft. ft. in.
$ilndustrial/Commercial DResidential Water Supply(shared)
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite
®*Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
®,Aquifer Recharge 0 Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
$IAquifer Test 0Stonnwater Drainage ft. ft.
*,Experimental Technology 0 Subsidence Control ft. ft.
®*Geothermal(Closed Loop) OTracer 20;DRILLING LOG(attach additional sheets if'necessary) -
FRO1 I TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) 01 Other(explain under#21 Remarks)
0 ft. 105 ft• Clay
4.Date Well(s)Completed: 03/13/24 Well ID# 105 ft. 185 ft. Granite
5a.Well Location: ft. ft.
17
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Randan Walsh a Wesley urbaNaentivnaik Buildersft. ft. `" •,<'1....r: °d 1,,,,,::..;.'
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR 0 & 2024
485 Timberlane Rd. Waynesville 28786 ft. ft.
Physical Address,City,and Zip ft. ft. i.-/Wi 1110
Haywood 7683-89-8082 2t.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. rtific tion:
35.437 N -83.068 W •
J�J
t 03/13/24
6.Is(are)the well(s)1Permanent or DTemporary rgnature f 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: lYes or 13 No with ISA 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:1 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: i
10.Static water level below topof 40
casing: (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) 30 Method of test: 2 hours 24c.For Water Supply&Iniecttion 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016