GW1--02998_Well Construction - GW1_20240520

11lilt I VIIIl
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2418 0 it 205 ft• ,sa,,,
205 ft" 305 fI• 2 5 epm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 23 ft. 6 1/4 in. I PVC
Company Name
W P23-150 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
.Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite
Monitoring 0 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO M%TERI Al. EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSC till ION(color,hardness,soil/rock ripe,grain size,etc.)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) D ft. 23 ft. Clay
4.Date Well(s)Completed: 04/03/24 Well ID# 23 ft.
345 ft. Granite
5a.Well Location: ft. ft.
Scott Cope ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
120 Cope Cove Rd. Penrose 28766 ft. ft. MAY 2 0 2024
Physical Address,City,and Zip ft. ft.
Transylvania 9516-86-8255 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.C> .ion:
35.250 -82.621 W - �
c40 04/03/24
6.Is(are)the well(s)1X Permanent or Temporary Signature if Certified well ontractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ©No with 1SA NCAC 02C.0100 or 15A 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:
You may use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 345 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if derent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: 2 hours 24c.For Water Supply&Infection 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: 63 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