GW1-2021-00436_Well Construction - GW1_20210201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.'A ell Contractor Information:
Terry White IL WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-B 5 ft 11 ft
(t. ft
NC Well Carona.,Certification Number IS.OUTER CASING fw ndY-used webs OR WNER
IET FROM TO DIAMETER THICKNESS MATERIAL
fL h. in
Company Name 16.INNER CASING OR TUBING e
2.W'PII Construction Permit k: FROM TO DIAMETER THICKNESS MATERIAL
It.,t anopprtntnre n<rr omnrnucrton rmh.,ae-I'V Oman'state. Var;mnce,etc-I 0 IL 4 fit 2 in SCh40 PVC
3.W'ell Use(check well use): S. ft. in
Water Supply Nell: 17.SCREEN
PROM I TO I DIAMETER I SI.OTSIZE I THICKNESS I MATERIAL
Agricultural [)Municipal/Public 4 ft 11 ft 2 1m 0.010 SCh40 JPVC
Geothermal(Heating/Cooling Supply) []Residenhal Water Supply(single) Ic ft a..
Industrial/Commercial Residential Water Supply (shared) IS.GROUT
'llit-gation mom TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft. 3 h• Bentonite Poured/25LB
Monitoring DRecovery 0 ft- 2 ft- Cement Poured/501-b
Injection Well:
fit fit
Aquifer Recharge OGroundwaler Remediation If SAND/GRAVLL PACRB
Aquifer Storage and Recover} Salinity Barrier mom I TO MATERIAL EMPIACEMENTTIAMOD
Aquifer Test Storm valer Drainage 3 R. 11 h. 4t2 Sand Poured
Experimental Technology- Subsidence Comml ft I R
Geothermal(Closed Loop) Tracer 20.DRRd.ING LOG funnels dtltid Himessui
(neothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) mom
TO DESCRIPTION oak,hsrae a Vv k ma.eu.
1/26/2021 MW-4 f lit
See Consultant Log
4.Date Well(s)Completed: Well IUH
Sa.Well Location: fit ft
BP Gas Station ft. ft.
FaciIov'0wner Name Faolit, Da(ifapi,kcable) ft. ft.
5171 Jonathan Creek Rd. Waynesville 28785 ft. h. F ,
Physical Address.City.and Zip f. R
Haywood 21.REMARKS
Couno Parcel ldentficauon No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35 35 38.30 N 83031.40 W, zztM4 Gf1� 1/28/2021
6.Is(are)the well(s)Ox Permanent or Temporary Signature emfiad Well C'mtaaor Date
Hv ,gmng Ihtr/rat.I herehv cen,/i tive the xr/¢.q wus f�'ero a,mrmord nr ne�.ndanae
7.Is this a repair to an existing well: Yes or �R No anti lsA,V(A( 02C.0100 mr Lf,I,v(A( ON 0'00 Well ron,vnlchnn stmrul rd.anJ deal o
11 thc,a rawer,fill ow known.ell emnemmmmo...m mrimn and eiplmm the nutmre olrhe "I',aJrhta rr,ord ems heen pmru4-J Ia rA .v-Il o.vmr
repair under 1/renmrk,eecnun orwthr Auek fJns(rum
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 I GW-I is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
4nr mrdnple wr/Iv(Ln all deprhs Jdff rern/example-3©1W'mnd2(dto9) construction to the following.
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
yirw,,level;.:mhoeezaamg,use 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Au above, also submit one cop)of this form within 30 days of completion of well
12.Well construction method: Auger construction to the following.
ue.auger rotary,rabice..direct push e¢.1
Division of Water Resources,Cnderground Injection Control Program,
FOR WATER SUPPLY W'ELLS CINIA: 16M Mail Service Center,Raleigh,NC 27699-1636
13%Yield(gpm) Method of test: 24e. For Water Supply At Iniection Wells: In addition to sending the Corm to
the addresses) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constmcted-
Form G W-I North Camlma Department of En,mm ncruil Qualify-Division of Water Resource Revrsed 2-22-2016