GW1--03962_Well Construction - GW1_20240705

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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
2418 o ft. 225 ft. ,,,
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Greene Brothers Well & Pump. WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 62 ft. 61/4 in. PVC
Company Name
OSS-2024-0232 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
0 Agricultural °Municipal/Public ft. ft. in.
fGeothennal(Heating/Cooling Supply) x°Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
11 IrrigationFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite
°Monitoring ®Recovery ft. ft.
Injection Well: it. ft.
°Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery ElSalinity Barrier FROM To t\TFR141. FMI'I.ACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. it.
Experimental Technology OSubsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM ' TO DLS(RIPTION(color,hardness,soiUrock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks) 0 ft. 62 ft. Clay
4.Date Well(s)Completed:06/03/24 Weil ID# 62 ft' 245 ft' Granite
5a.Well Location: ft. ft. i 't.-`P L Z%v Li
Cottages at Byron Forest LLC ft. ft.
Facility/Owner Name Facility 113#(if applicable)
ft. ft. JUL 0 2024
200 Byron Forest Dr. Mills River 28759 ft. ft. ir,(;p;rrei;Cil ii•r/seewigng Unit
Physical Address,City,and Zip
ft. ft. DA Ci304
Henderson REID10011081 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) rrtifi tion:
35.348 N -82.561
%Lk 0 `r 06/03/24
6.Is(are)the well(s)D% Permanent or DTemporary Signature of Certified Well Con ""r— 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 or )No with ISA NCAC 02C.0100 or ISA 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 245 (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: 60 (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) 40 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: 43 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