GW1--04649_Well Construction - GW1_20240809

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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- 405 ft. izca
2418
ft. ft.
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. 87 ft. 61/4 in, PVC
Company Name
O S S-2024-0581 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
0Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
('Irrigation FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: o ft. 20 ft' Bentonite
°Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
IDAquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
[(Aquifer Storage and Recovery °Salinity Barrier FROM TO M%TERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks) o ft. 87 it. Clay
4.Date Well(s)Completed: 06/20/24 Well ID# 67 ft• 425 ft' Granite
5a.Well Location: ft. ft. .I'.
—. ' :a . )
Cottages at Byron Forest ft. ft. ((__
Facility/Owner Name Facility ID#(if applicable) ft. ft. 0 U sJ 2024
218 Byron Forest Mills River 28759 ft. ft.
Physical Address,City,and Zip ft. ft. (�`i r� i:r;�
Henderson 9630-80-3691 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.C• u on:
35.348 -82.561 161:;•
W 06/24/24
6.Is(are)the well(s)�IX Permanent or DI emporary 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: DYes or I3No 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 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:r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (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: 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 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) 12 Method of test: 2 hours 24c.For Water Suonlv&Infection 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: Hill Amount: 78 tabs completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016