GW1--03028_Well Construction - GW1_20240520

I 1 11l 1 lJ 11
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: `
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
4238 0 rt. 220 ft. Yswn
220 ft' 300 ft' is gam 3w5w56S5Pm
NC Well Contractor Certification Number i
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. 37 ft. 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
JMQ-339W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O Agricultural 0Municipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
OIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonite
QMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO M ATERfu. EMPLACEMENT METHOD -
0 Aquifer Test DStormwater Drainage ft. ft.
OExperimental Technology InSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
0Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I To I DF.S('Ripi ION(color,hardness,sail/rock t)pe,grain size,etc.)
o ft. 37 ft. Clay
4.Date Well(s)Completed:03/14/24 Well ID# 37 ft• 510 ft.
Granite
ft. ft.
5a.Well Location: -
John David Wilson/Jeanette White ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. MAY 2 0 2024
149 L and E Meadows Dr.Waynesville 28786 ft. ft. ,--,.,, . _,, : .r,
_ Ir,`
Physical Address,City,and Zip ft. ft.
Haywood 8634-54-2722 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.Certification:
35.458 N -82.912 W
otiet, i. c,eti_j2....._
03/14/24
6.Is(are)the well(s)OX Permanent or 0Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certibi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or x®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:
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: 510 (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
12.Well construction method:
Rotary above,also submit one copy of this form within 30 days of completion of well
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) 60 Method of test: 2 hours 24c.For Water Suouly&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: 93 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