GW1--03970_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Travis Greene 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
o ft. 75 ft. sow
4238
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 'cable)
Greene Brothers Well & Pump WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 25 ft* 61/4 in. Steel
Company Name
D M C-012 W 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
Agricultural ®Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
ElIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
I/ FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o 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 MATERI at EMPLACEMENT METHOD
()Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
OGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc..)
OGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o ft. 25 tt. Clay
4.Date Well(s) 05/30/24 Completed: Well 1D# 25 ft. 90 ft. Granite f ' !� -*
ft. ft. �.
5a.Well Location:
John Dallas ft.
ft. JUL 0 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14545 Cruso Rd. Canton 28716 ft. ft. lrtfa:�- t'r ',/�4.
ft. ft.
Physical Address,City,and Zip
Haywood 8662-34-9579 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-
35.404 N -82.811
/ 05/30/24
6.Is(are)the well(s)CX Permanent or DTenrporary 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: )Yes or XO 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 concnvetion in(unmNon 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:
S.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: 90 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii Idit[jerent(example-3@200'and 2@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 Iniection 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) 50 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: 16 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