GW1--03021_Well Construction - GW1_20240520

.WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2418 o ft. 460 ft. a„„„
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if 'cable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 95 ft. 61/4 in. PVC
Company Name
OSS-2024-0001q-k 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: P� 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
ID Agricultural DMunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
O Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o IL 20 ft• Bentonite
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
IDAquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery D Salinity Barrier FROM TO M%TERI\I. EMPI.4 CEMENT METHOD
0 Aquifer Test QStormwaterDrainage ft. ft.
0 Experimental Technology D Subsidence Control ft. ft.
0Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o ft. 95 ft. Clay
4.Date Wells Com leted: 03/20/24 Well ID# 95 tt• 525 ft'O PGranite
ft. ft.
5a.Well Location:
Cottages at Byron Forest, LLC ft. ft.
Facility/Owner Name Facility lD#(if applicable)
ft. ft.
181 Byron Forest Dr. Mills River 28759 ft. ft. _ MAY 2 0 ?OM
Physical Address,City,and Zip ft. ft.
Henderson REID 10011089 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22 ''cation:
35.348 -82.562 N W
11-31N-- 03/20/24
6.Is(are)the well(s)Dx Permanent or Temporary Signa re of Certified Well Contractor Uatc
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: QYes or E3 No with 1SA 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: 525 (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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 2 hours 24c.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: 96 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016