GW1--03024_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 ft. 205 ft. io yam
2418
205 ft. 285 ft. 5 gore
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 23 ft. 61/4 in. Steel
Company Name
J M Q-34 9 W 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): It. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
lo Agricultural DMunicipa1/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
DIndustrial/Commercial Residential Water Supply(shared) 18.GROUT
11Irrigation FROM TO MATERI.AI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite
Monitoring ORecovery ft. ft.
Injection Well: ft. ft -()Aquifer Recharge Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
inAquiferStorage and Recovery DSalinity Barrier FRONt TO NTATERIAl. F.MI'LaCEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
QExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) DTracer r20.DRILLING LOG(attach additional sheets if necessary)
F R1)\l TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 23 ft* Clay
4.Date Well(s)Completed: 04/15/24 Well ID# 23 It• 305 ft.
pGranite
5a.Well Location: ft. ft. t---
Melinda McCracken ft. ft. MAY 2 0 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Cupstid Ridge Canton 28716 ft. ft. lrl`� ; `A.:' 4J : '' '
Physical Address,City,and Zip
ft. ft.
Haywood 8662-59-5053 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. *on:
35.418 N -82.809 W
04/15/24
�.1 I !-73
6.Is(are)the well(s)Jx Permanent or ['fcmporary Signature of ertified Well Contractor Date
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: ®Yes or El 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 in/ormation and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I 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: 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: 5 (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) 15 Method of test: 2 hours 24c.For Water SuDDly&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: 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 Revised 2-22-2016