GW1-2021-03464_Well Construction - GW1_20210607

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- 205 ft. 7som
2418
ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING(for 1H-cased wells OR LINER if a licable
Greene Brothers Well & Pump, W mu AM
T Inc. FROM TO DIETER THICKNESS MATERIAL
0 [t. 82 ft. 61/4 in. Steel
Company Name
MCM-202W 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): tt. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in. i
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite'
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) E3 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type, rain size,etc.)
0 ft. 82 ft. Clay I
4.Date Weil(s)Completed: 04/28/21 Well ID# 92 ft. 405 ft.
Granite
ft. ft.
5a.Well Location:
Richard &Shay Hyatt
Facility/Owner Name Facility ID#(if applicable) ft. ft. REQ 1
John Vance Rd Waynesville 28786
Physical Address,City,and Zip
Haywood 8634-67-4224 21.REMARKS
I'1 arr�' Plrceeesing
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. ertifiea on
35.465 N 82.909 W 04/28/21
6.Is(are)the well(s)OPermanent or Temporary 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: ®Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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: 405 (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 easing: 20 (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,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 2 Hours 24c.For Water Supply& Injection 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: 74 Tabs completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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