GW1--03031_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 It 285 ft. 12
2418
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 NIAIIRI'sl
0 R. 27 ft. 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING
J M Q-350 W (geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG 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 ()Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) x()Residential Water Supply(single) ft. ft. in.
0Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' Bentonite
0Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
()Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
()Aquifer Storage and Recovery E)Salinity Barrier FROM TO NIATFRIAI. EMPLACEMENT METHOD
()Aquifer Test 0Stormwater Drainage ft, ft.
0 Experimental Technology []Subsidence Control ft. ft.
()Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock tspc,grain size,etc.)
()Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) 0 ft. 27 ft. Clay
4.Date Well(s)Completed: 04/25/24 Well ilidl 27 ft. 305 ft. Granite
ft. ft.
5a.Well Location: w , +...
Thomas Halrlil ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. R. 41 rn Y 0 C G
?4
1460 Chestnut Flats.Ln. Waynesville 28786 ft. ft.
ft. ft. r;:..;.;7;.
-�Physical Address,City,and Zip
Haywood 7695-25-2031 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce c on:
35.481 N -83.058 w
La4kY04/25/24
6.Is(are)the well(s)lx Permanent or ()Temporary Signature Certified well Contractor flue
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: DYes or x()No with 15A NCAC 02C.0100 or I5A 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#1I 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: 100 (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) 12 Method of test: 2 hours 24c.For Water Supply&iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I 3b.Disinfection type: HTH Amount: 56 labs 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