GW1--03848_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
o ft- 165 rt- topom
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 MATERIAL
0 ft. 34 ft. 61/4 in. PVC
Company Name
MC M-430 W 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: 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. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XQResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: o ft• 20 rt• Bentonite
Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO AI-AT1'Itl l EMPI %CEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.l
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o ft. 34 ft. Clay
4.Date Well(s)Completed:04/17/24 Well ID# 34 ft• 185 ft* Granite
ft. ft.
5a.Well Location:
Robert Wood ft. ft. _ `
FacilityiOwncr Name Facility ID#(if applicable) ft. ft. J .,/
1702 Riverside Dr. Clyde 28721 ft. ft. JUN 9 8 2024
ft. ft.
Physical Address,City,and Zip
Haywood 8629-39-2348 21.REMARKS Irks;r.r.i•Ir to r°-e.raAs:•,g 11•41
DI.C iC4;
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• : cation:
35.608 N -82.960
iU �_ 04/17/24
6.Is(are)the well(s)JX Permanent or DTeniporar`. [gnat a 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 o r 0 No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inlormauon and r'plain 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: 185 (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(4200'and 2Q100) construction to the following:
10.Static water level below top of casing: 20 (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) 10 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
I 3b.Disinfection type: HTH Amount: 33 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