GW1-2021-07054_Well Construction - GW1_20211129

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JCLM•SUn 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
O It III tt• 1'yDI101.J
LfQ q �^ A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
O � I/l��t �„ w FROM fL [_10 ft DIAMETER to THICKNESS MATERIAL
Company Name 1 `l 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: �l t- as 4 ID 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) G fL '75' ft. 6
�.9�j in. • �g s ,
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN 4
PP Y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural JDMu ipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial ,- DResidential.Water Supply(shared) MGROUT, r i "-rt
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' 2.0 ft' nl}t PO(d
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK ifa licable '
I Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology n
J Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheers ifnecessa
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
O ft. -15 ft. Cj4 6ver6
4.Date Well(s)Completed: 7-21 Well ID# If ft- 1 92' VQ n t yC
5a.Well Location: ft. ft.
/+ r ft. ft.
s t
al yywabblf R-2Cnr-r� NOVFacility/Owner Name Facility ID4(ifapplicablc) ft. ft. N
0 TSial% 12d. Colmm6u.i . NG 2977Z ft ft. -
Physical Address,City,and Zip ft
pD 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:
ri
350 v n a2• 7d, $'t° 51' 44 .6367% W It- 11-21
6.Is(are)the well(s)&Prermanent or Temporary gnature 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: nYes or o with I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ijihis is a repair,fill out known we//construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[ferem(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (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: (o• Z (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
�bl ��r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: T 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
i
t
13a.Yield(gpm) Method of test: GI• Conlm. 24c. For Water Supply& Iniection Wells: In addition to sending the form to
11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: O,h\% t C D_ Amount: 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

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Owner: r arjS New Nell:
Address: -T5-a% I�. Repair:
of U,m 6"S Pic. 28' 2Z
Ike* dw the obom AVwauejwQ nangiwiW ire amnimee n"dl Say%wd co weu Rates:
Well DrIDer: i t Certificatio 0...4m n
Well Driller Signature: 2 I
Date Grouted:
a s ructio fo it'
Total Depth,.
.....� Type :&6,nt
Casing Type:-
Casing Depth: _'LS Depth.
Diameter: w . 2 S7- - Method: azir-
WelghtfThicimess...-
Height: Iy�s . at ' V c5LAWJ
Drive Shoe:
GPM New: lam=D
Upon completion of this form please return to the Haywood County Environmental
Hmkk Depaoxent or fax to the number above within 48 hours of Self-Cendificadom
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