GW1--03033_Well Construction - GW1_20240520

1 ........
V1111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: `1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft. 245 ft. 25
4238
245 ft. 320 ft• 550,
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. 36 ft. 61/4 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: DGS-095W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) It. ft. in.
-
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
0 Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) x�Residential Water Supply(single) rt. . ft. in.
0 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1° )irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o IL 20 ft. Bentonite
D\Ionitoring ®Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Ej Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERI Al. EMPLACEMENT METHOD
IDAquifer Test DStormwater Drainage ft. ft.
0Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DI Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock hype,grain size,etc.)
0 Geothermal(Heating/Cooling Return i nOther(explain under#21 Remarks) 0 ft. 36 ft. Clay
4.Date Well(s)Completed: 04/17/24 Well ID# 36 ft. 345 ft' Granite
ft.
5a.Well Location: ft.- .` ...., . I _,.. r !
Jacob Reynolds ft. ft.
Facility/Owner Name FacilityiD#(ifapplicable) It. ft. - MAY 2 0 ?U?4
645 Van Arrington Rd. Clyde 28721 ft. ft.
ft. ft.
Physical Address,City,and Zip
Haywood 8721-18-7044 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:
35.58 N -82.967 W
04/17/24
6.Is(are)the well(s)Ox Permanent or Temporary Signature of Certified 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: DYes or E3 No with 15A 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.
dulled'' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (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 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) 8 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: 63 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