GW1--03960_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Robin Webb 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 ft- 405 ft• lo(5)gpm
2418
405 ft' 505 ft. 12i5leam
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER(if ap licable)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 103 ft• 61/4 in. PVC
Company Name
W I22100102822 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.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
lgricultural El Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared)
18.GROUT
urination FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Bentonite
Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Q Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO M%TERIAI. EMPLACEMENT METHOD _
Aquifer Test 0StormwaterDrainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
o ft. 103 ft• Clay
4.Date Well(s)Completed:04/30/24 Well ID# 103 ft• 605 ft' Granite
5a.Well Location: fr. ft. L i •I V E u
William Nash
ft. ft. � •t_i
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUL 0 c 2024
t31 Wyatt Andrew Rd. Mills River 28759 ft. ft. lrforirs ' 1'., _v'Japr=
Physical Address,City,and Zip ft. ft. i.711 CJ AC4
Henderson 9631-00-2380 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) elp ation:
35.374 -82.589
01.►e'lk, l_, 04/30/24
6.Is(are)the well(s)OX Permanent or Temporary Signature of Certified Well Contractor U:uc
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 Ei.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. 23r SitO 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: 605 (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 1@100) construction to the following:
10.Static water level below top of casing: 40 (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) Method of test: 2 hours 24c.For Water Suoplv& 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: 109 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016