GW1--02120_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Robin Webb -14:WATER ZONES r`t :' ,
Well Contractor Name FROM TO DESCRIPTION
0 ft. 185 ft• isw,,
2418
ft. ft.
NC Well Contractor Certification Number 15.:OUTER CASING(for-multi-cased;wells)OR LINERR(if ap licable-
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 61 ft• 61/4 , ill. PVC
Company Name •'16.INNER CASING OR.TUBING;:(geothermal dosed-loop) "_°• ' '
2.Well Construction Permit#: WEL2022-00598 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: — 1li SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
®'Agricultural QMunicipal/Public ft. ft. in.
X'Geothetmal(Heating/Cooling Supply) ID Residential Water Supply(single) ft. ft. in.
®'Industrial/Commercial ['Residential Water Supply(shared) 18.GROUT:
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 61 ft• Bentonite Pumped full length
®'Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
*I Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable);: ,
*Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
"Aquifer Test QI_ Stonnwater Drainage ft. ft.
X(Experimental Technology D Subsidence Control ft. ft. .
*Geothermal(Closed Loop) 0Tracer ,•20.:DRILLING LOG(attach additional sheets ifnecessary) ,_ ; ' -_-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*(Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
0 ft, 61 ft• Clay 1
4.Date Well(s)Completed: 02/28/24 Well ID# 61 ft' 205 ft' Granite
ft. ft. r.:: i ,4
5a.Well Location: ! �. 1�.% s""`,;
Dirt&Sticks Inc ft. ft. APR
c cOZ
4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
104 Wimberly Rd. Swannanoa 28778 ft. ft. K„r^';f.,71 ^rn, ,4'.;,5,UgYi
ft. ft. vva l%1:3
Physical Address,City,and Zip
Buncombe 9689-10-4572 s21;RENIARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one lat/longsufficient)•is 22. • • �on:
35.599 N �
-82.426 W 02/28/24
, (_1 - 0
ignature o4..t6ertified Well Contractor Date
6.Is(are)the well(s)JPermanent or )Temporary
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
I=7
7.Is this a repair to an existing well: )Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown 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: 205 (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 Serviee Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: 2 hours 24c.For Water Suppiv&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: 36 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 Resourcesi Revised 2-22-2016