GW1--03966_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4238 0 ft• 160 ft. 2o,
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. 65 ft. 61/4 in, PVC
Company Name
M CM-111 W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATI:RIM.
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft. ft. ' in. '
Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
I-1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• 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 M%TERI%I. EMPLACEMENT METHOD
°Aquifer Test 0Stormwater Drainage ft. ft.
°Experimental Technology 0 Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,erc.l
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. 65 ft• Clay
4.Date Well(s)Completed: 04/24/24 Well ID# 65 ft. 165 tt.
PGranite
5a.Well Location: ft. ft. j.`�:_`-�:lv E[,
Kaitlyn &Brandon Worley ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUL 0 ` 2024
252 Garden Ln. Canton 28716 ft. ft. irAer>arwi e,i ;•,r..•,,,,,-,,unit
Physical Address,City,and Zip ft. ft. DVS(;aul
Haywood 8656-34-8299 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.Certaation•
35.514 N -82.852 W Q/' 04/24/24
6.Is(are)the well(s)OX Permanent or Temporary Signature o 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 DI No with 15A 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:
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@200'and 2@100) construction to the following:
1
10.Static water level below top of casing: 00 (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) 20 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: 30 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