GW1--03971_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
0 ft. 100 ft• 3.4(.rs)mm
4238
10o ft- 645 ft. 3,5(375)9P^
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. 50 ft. 6 1/4 in. PVC
Company Name
M C M-429 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 SITE THICKNESS MATERIAL
()Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft. ft. in.
O Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO M:STERIA I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft• Bentonite
aMonitoring 0Recovery ft. ft.
Injection Well: ft. ft.
O Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERAAI. EMPLACEMENT METHOD
0 Aquifer Test 13Stormwater Drainage ft. ft.
0 Experimental Technology QSubsidence Control ft. ft.
13Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To I DESCRIPTION(color,hardness,sail,rock type,grain size,etc.)
o ft. 50 ft• Clay
4.Date Well(s)Completed:05/30/24 Well ID# 50 ft• 665 ff• Granite
ft. ft.
5a.Well Location:
Charles&Frances Wright/Bob Day ft. ft. + .. ••1
L.Facility/Owner Name Facility ID#(if applicable) ft. ft. `‘` L. �/
Clark Rd.Clyde 28721 ft. ft. JUL 0 5 2024
Physical Address,City,and Zip ft. ft. Ir or.r•.t;.i,A.1 a
Haywood 8730-76-8490 21.REMARKS DlA,C,1C44 .S
unit
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:
35.626 -82.909 N W
d4rccc_,« 06/12/24
6.Is(are)the well(s)j% Permanent or [)Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert f that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E3 No with 15A 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.
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: 665 (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: 280 (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) 4 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: 118 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