GW1--03999_Well Construction - GW1_20240708

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 n. 305 H• ,w(.75)sn*
2418
305 ft• 405 ft• tw pst is"
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a icabk)
Greene Brothers Well &Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 60 ft* 61/4 in. PVC
Company Name
WP23-087 16.1NNER 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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
1.
irrigation 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 IDGroundwater Remcdiation _
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery E3 SalinityBarrier
FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (Other(explain under i121 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain sirs etc.)
0 ft• 60 ft• Clay
4.Date Well(s)Completed:06/07/24 Well ID# 60 fl 705 n
PGranite
ft. ft.
5a.Well Location:
Keith &Jane Shockley ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. s..-•`.f - R
ve...,..
,.,.... , ,,.,
432 Woodwind Dr. Pisgah Forest 28768 ft. ft. �.
Physical Address,City,and Zip ft. ft. p ZOO
Transylvania 8595-41-7453-000 21.REMARKS
Y iri6:attic.;n; .',
County Parcel Identification No.(PIN) at.i.v 1i .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'ong is sufficient) 22. il),eation•
35.208 -82.700
N W 06/07/24
6.Is(are)the well(s)1x Permanent or Temporary Signature of Certified Well Contractor Date
By signing this/nm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or X)No rsl//t 1SA NCAC 02C.0100 or 15.4 NC9C 02C.0200 Well Construction Standards and that a
If this is a repair,ill 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: 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(0200'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 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) 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 CW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016