GW1--03030_Well Construction - GW1_20240520

1 I 1111t 1 t!i
WJLL ONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 o fL 145 ft• 25aw,,
ft. ft.
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
p It. 80 ft. 61/4 in. PVC
Company Name
GJB-1 95W 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 OMunicipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
OIndustrial/Commercial OResidential Water Supply(shared) ,..-
in.GROUT
Irrigation FROM TO MATERIAL IMP!.\CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite
°Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERI4I. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) D Other(explain under#2I Remarks) 0 ft. 8p ft. Clay
4.Date Well(s)Completed: 04/22/24 Well ID# 80 ft. 165 ft. . .
P Granite ,...C . 4...r i/ t.-..
ft. ft.
5a-Well Location:
Sears Paxton ft. ft. MAY 2 U ZDZ4
Facility/Owner Name Facility ID#(if applicable) tt. ft. ir.`_...-,; :.7' -rV-L'..-g Uri(
115 Woodland Dr. Canton 28716 ft. ft. G';VCuR
ft. ft.
Physical Address,City,and Zip
Haywood 8678-38-0227 21.REMARKS
County Parcel Identification ication No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.582 N -82.789 W
•o%---,�, c i..„_ 04/22/24
6.Is(are)the well(s)D% Permanent or Eli cmporal.�. Signature of Certified Well ontractor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 V'es 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:
S.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: 165 (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: 80 (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) 25 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: 29 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