GW1--02179_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I'
Travis Greene
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft' 240 ft• syam
350 ft• 285 ft• 24 gpm 1 '
NC Well Contractor Certification Number -15:OUTER CASING(for multi-casedhwells)OR;LINER(if ap licable)``-
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. 61/4 I in. Steel
Company Name -.16.INNER CASING OR TUBING(geothermal closed-loop) ' ' `
2.Well Construction Permit#:405412-1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,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.
itGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
llIndustrial/Commercial DResidential Water Supply(shared) :.,18.
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonite
MI Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
NI Aquifer Recharge 0 Groundwater Remediation
'19.'SAND/GRAVEL,PACK(if applicable)' - ,. -
NlAquifer Storage and Recovery JISalinity Barrier FROM TO MATERIAL ; EMPLACEMENT METHOD
INIAquifer Test DStonnwater Drainage ft. ft.
11 Experimental Technology D Subsidence Control ft. ft. i
NI Geothermal(Closed Loop) OITracer '20.DRILLING.LOG(attach additional sheets if necessary) . -
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
MI (Heating/Cooling Return) -I Other(explain under#21 Remarks) o ft. 90 ft. Clay
4.Date Well(s)Completed: 03/11/24 Well EN 90 ft' 305 ft' Granite
5a.Well Location: ft. ft. I r--- „_
1.Lisa Adler/828 Construction ft. ft. F .� �,,,4'L.:ii a 9; _
l,; Li:
ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR n n n 0' 2104
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18905 North Carolina 209 Hot Springs 28743 ft. ft. -::' ,4
Physical Address,City,and Zip ft. ft. Iflii;r ri-i:cPc,t tr :.'T".mot:.... : .6(1t i
ia. %,/V)(;.
21.REMARKS
Madison 8743-72-7166 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.699 N -82,882 w
14,�,� ,ti��t.� 03/11/24
6.Is(are)the well(s) Permanent or Temporary tgnature of Ccrtifie- ell Contractor Date
By signing this form,I hereby certt)5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jNo 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 it formation and explain the nature of the copy of this record has been provided to the well owner.
I
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: 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: 60 (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 benter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: 2'hours 24e.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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016