GW1--04647_Well Construction - GW1_20240809

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 H. 305 ft. atm:a
2418 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 44 ft. 61/4 in. PVC
Company Name
OS S-2024-0582 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) x()Residential Water Supply(single) ft. It. in.
0 Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
',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 OGroundwater Remediatinn 19 SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM — TO MATERI%I. P.i�IPL aCF\IFNT METHOD
Aquifer Test ()Stormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
()Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 1 TO I DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
()Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 44 ft. Clay • /
4.Date Well(s)Completed: 06/20/24 Well ID# 44 ft. 325 ft' Granite .''— %• 0,a••• t S_L.,
5a.Well Location:
ft. ft. Aiii, 0 5 2024
Cottages at Byron Forest ft. ft.
rt. ft. Ir,.—.-4::-I '-r'WA-.g licit
Facility/Owner Name Facility Ilkt(if applicable) Eyi c 4l'Si
199 Byron Forest Mills River 28759 ft. ft.
Physical Address,City,and Zip R. ft.
Henderson 9630-80-1838 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22. 1 fie on•
35.348 -82.561
'ta. C Q7 06/20/24
6.Is(are)the well(s)Ox Permanent or D Tempo rar� Signa 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 F3 No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill ow 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:T SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (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{a)200'and 2@100) construction to the following:
10.Static water level below top of casing: 140 (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
12.Well construction method:
Rotary above,also submit one copy of this form within 30 days of completion of well
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) 9 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: so tabs completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016