GW1--04657_Well Construction - GW1_20240809

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 R• 245 ft. ,o,
4238
ft. ft.
NC Well Contra:for Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS M.ATERI.A I.
0 ft. 115 ft. 6 1/4 in. PVC
Company Name
J M Q-29$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.UIG 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
QAgricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) xDRcsidential Water Supply(single) ft ft in.
o Industrial/Commercial ID Residential Water Supply(shared) 18.GROUT
I ' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
0Monitoring 0Recovery ft. ft.
Injection Well: ft. R.
OAquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATE RI AL EMPLACEMENT METHOD
0Aquifer Test IDStormwater Drainage ft. ft.
DExperimental Technology IDSubsidence Control ft. ft.
QGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION I color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) [,Other(explain under#21 Remarks)
o ft. 115 ft. Clay
4.Date Well(s)Completed: 06/26/24 Well ID# 115 ft' 285 ft. Granite
5a.Well Location: ft.
ft. C��r'
Ariel Popiel/Youlia Tzenova ft. ft. .. I._`
—
F,,,,iiiv Owner me Facility ft., ft. 11/6U v J Z02¢
Na
Page Rd. Waynesville 28786 ft. ft. 1I,;.,;,;;,.:-„ ,-rr .• l
kit
Physical Address,City,and Lip ft. ft. I ii° , t'
Haywood 8604-08-8988 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.Certification:
35.466 N -83.028
(:, �W.ontractor.,_ 06/26/24
6.Is(are)the well(s)fX Permanent or Temporary Signature of Certifie `s 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: QYes or i3 No 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (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 c@100') construction to the following:
10.Static water level below top of casing: 60 (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) 10 Method of test: 2 hours 24c.For Water SUDDIV& 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: HTH Amount: 51 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