GW1--03998_Well Construction - GW1_20240708

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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
0 ft- 305 it- 1M(.75)gpm
2418
305 ft• 405 fl. 111(.75)gpm
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. 60 ft. 6 1/4 in. PVC
Company Name
WP23-087 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. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural OMunicipal/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) inResidential Water Supply(single) ft. ft. in.
0 industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
flIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery O Salinity Barrier FROM TO M ATERIA1, EMPLACEMENT METHOD
0 Aquifer Test O Stormwater Drainage ft. ft.
0 Experimental Technology OSubsidence Control ft. ft.
'Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO I DESCRIPTION(color,hardness,soil/rock hype,grain size,etc.)
OGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o f• so ft. Clay
4.Date Well(s)Completed:06/07/24 Well ID# 60 ft• 705 ft' Granite
5a.Well Location: ft. ft. t.- h.-; I
It. it. �`C.•E V E L
Keith &Jane Shockley
Facility/Owner Name Facility iD#(if applicable) R. ft. J IJ L V 8 2024
432 Woodwind Dr. Pisgah Forest 28768 ft. ft.
li I!v.tilt. `�T ' vvtr-�{Uri:
Physical Address,City,and Zip ft. ft. l 1 i,;.'!...-.3
Transylvania 8595-41-7453-000 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. ation:
35.208 N -82.700 �, ( (%'
06/07/24
6.Is(are)the well(s)C3Permanent or OTemporary 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: OYes or 13 No with 1SA 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 djagrAtlt 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: 705 (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: 300 (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
LL 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) 1/2(•5)gpm 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: 127 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