GW1--03017_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 n- 265 ft. w m,
2418
ft. D.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(it ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 fL 85 ft' 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
OSS-2024-0009 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
0 Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
13Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
nIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o it 20 ft' Bentonite
aMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery D Salinity Barrier FROM TO M tTERI U. EMPL.ACEIIF\T METHOD
13 Aquifer Test El Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks) FRU't I TO I DESCRIPTION(color,hardness soil/rockh'pc grain size,etc.)
0 ft. 85 ft. Clay
03/18/24 -•"
4.Date Well(s)Completed: Well ID# 65 ft. 285 ft. Granite y ; 11 j-_,a J
ft. ft.
5a.Well Location: MAY 2 0 2024
Brian Kirk ft. ft.
Facilityi Owner Name Facility ID#(if applicable) ft. ft. - y,a .
190 Byron Forest Dr. Mills River 28759 Ir. _.
�11'ci,,; �
ft. ft.
ft. ft.
Physical Address,City,and Zip
Henderson REID 10011080 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cer a on:
35.347 N -82.562 W) .n&it 03/18/24
6.Is(are)the well(s)Dx Permanent or EtTemporary Signature o Certified Well Contractor Date
By signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or DNo 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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 Iniection 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) 10 Method of test: 2 hours 24c. For Water SuDDIv&Iniection 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: 51 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