GW1-2021-00434_Well Construction - GW1_20210201

PPiM Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 14.WATER TONES
wbtl Contractor Name FROM TO DESCRIPTION
3287-B 5 It 12
f. R
NC Well Contractor Certi&.lion Number 15.OUTER CASING foe eaYtl-tad weW OR LINER
IETFROM TO DIAMETER THICKNESS MATERIAL
R ft n.
Compare Name
141NNBR CASING OR 7UBEVCfaudanxiod elaed-Iw
2.µ'ell Construction Permit#: FROM To 11DLAMETER THICKNESS MATERIAL
f„r all appllcahla n,u a„rsrrurr,on 1arsoo r,. o/c,rnnnn.stale. Ino'nr" en) 0 It 4 It 2 Sch40 PVC
3.µ'ell Ise(check well use): It ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOTSIZE THICK!v c MATERIAL
Agricultural OMwicipal/Public 4 ft 12 ft 2 In' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) R fL of.
Industrial/Commercial ORealdcmfal Water Supply(shared)
16 GROUT
—lineation FROM TO .MATERIAL EMPLACEME.NTMETHOD&A.MOIINT
Non-Water Supply Well: 2 It 3 IL Bentonite Poured/251-6
Monitoring []Recovery 0 ft 2 R. Cement Poured/501-b
Injection Well: h h
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK fitapplicable)
Aquifer Storage and Recovers Salinity Banner FROM I TO MATERIAL EMPucEMENTME TIOD
Agmter Test OStormwater Drainage 3 ft- 12 ft- #2 Sand Poured
Experimental Technology Subsidence Control h h.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG Wtuala additional dwbK
Geothermal(Heating/Cooling Return) (hher(explain under#21 Remarks) FROM TO DES47RUMWN(.1e,OWvea,soW.],gm trami Aux,err.
ft It See Consultant Log
4.Date Wells)Completed: 1/26/2021 µell ID#M W-2 It h.
Sa.Well Location:
rt ft
BP Gas Station ft ft
„e
Facdip-Owner Name Facility lD#(Tapplicable) ft ft. iti -v
5171 Jonathan Creek Rd. Waynesville 28785
Physical Address,Ca ,and Yip f. IL
Haywood 21.REMARKS
Court' Parcel Idemification No.(PIN)
5b.Latitude and longitude in degrces/mioules/secoods or decimal degrees:
(if,ell field,one batons is sufficient) 21(edification:
35 35 38.30 N 83031.40 W a44 (�� 1/28/2021
OX 6.Is(ore)the well(s) Permanent or OTemporary s,Rnamre 'miffed Well Comraator Date
H, .,,00,an,J rm.I h,rehy Cerro rhm lire.,lr)n,, lu ere)eonelnmmd m m-ordann
7.Is this a repair to an existing well: []Yes or E)No a'oh/5A A'('At 02('.0100 or 15A A'CR 02( 0200 HWII osom,,Iinn.Standard,and#.,u
odors do a repay,fill run brown yell corurrua,on mfom,unan.nd,xplmn dh.native ofhe cr','ofdue re.nrdI."heen prov,ded" the wall ov-nr
k of
8.pFor Geoprobe/EIPT or Closed-Loop r
23.Site diagram or additional well details:
Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessarv.
drilled one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
I-br nruHdple wells no all d,,00 od ff..to lex,.ple-3(tr2itf) rd 2(inif fl') construction to the following.
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing I:nit,
If.merleve/Is oho,•,w'ong,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
IZ.WA construction method: Auger Qu above, also submit one copy of this form within 30 days of completion of well it c.auger,rotary,cable,direct push,etc) construction to the following.
Division of Water Resources,Iuderground Injection Control Program,
FOR WATER St IPPLY'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunnly& 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016