GW1--04646_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor information:
Travis Greene 14.WATER ZONES
Well Con .i for Name FROM TO DESCRIPTION
0 fi• 910 ft. wvm
4238
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Beattie)
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 108 ff• 61/4 in. PVC
Company Name
2023-25417-9-13708 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): it. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °MunicipaVPublic it. ft. in.
°Geothermal(Heating/Cooling Supply) X°Residential Water Supply(single) n• ft. in.
°Industrial/Coenmercial °Residential Water Supply(shared) 18.GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bentonite
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery ()Salinity Barrier FROM TO SI ATERI:11. EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO i DES(RIPTION(color,hardness,soil/rock hype,grain size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) o tt. 108 ft• Clay
4.Date Well(s)Completed: 07/11/24 Well ID# 108 rt. 920 ft.
P Granite .._ -
5a.Well Location: u. it. `-r 1.-. : Vr,,,tl.r
Mac Hi Mountain LLC ft. ft.
Facility/Owner Name Facility 1D#(if applicable) it. ft.
n II/3 4 3 2024
2355 Greenspire Dr. Sylva 28779 ft. ft. ir,;,:,:' :r, ;"-,"--, :-; ,v,.,t
Physical Address,City,and Zip ft. ft. rA r";('.,
Jackson 7684-05-6770 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:
35.456 N -83.100 W
`j - 1 07/11/24
6.Is(are)the well(s) X Permanent or �Temporar� Signature of Cer fled We 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: ID Yes or 0 No with 1SA NCAC 02C.0100 or 1SA 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 constnuction details. You may also attach additional pages if necessary.
drilled:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 920 (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@l00')
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) 60 Method of test: 2 hours 24c.For Water Supply&Iniection 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: HT/1Amount: tt'8 tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016