GW1-2021-08005_Well Construction - GW1_20211224

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2021-08005
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Email Address*
Contact Name* [e-mail]
Wayne Floyd m
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
.................... ................... ................... ................... ............... ................. ........... ............... ................... .....
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
.................................................
Certiticate# Cert Level First Name Last Name Company Name
4358 A WAYNE FLOYD WENDELL LEE WELL SERVICES, INC
2.Well Construction Permit#:
.................................................................... ...................................................
EH-21718
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

12/7/2021 P87-71 5
(gallons per minute)"
5.Well Location
Facility/Owner Name* Facility ID#
Philip Placank/John D. Hill none
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Polk P87-81
Physical Address* Street Address
305 Renard Rd
Address Line 2
City State/Province/Region
Tryon NC
Postal/Zip Code Country
28782 US
Latitude* 35.2160357000 Longitude*-82.1393302000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
305 surface?
For multiple wells list all depths if different 92
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
35 6.125
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
5 13a.Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH 18 oz.

14.WATER BEARING/FRACTURE ZONES
From To Description
115 120 3 gpm
in feet in feet
128 132 2 gpm
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.50 -92.00 6.13 SDR-21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
0.00 0.00 0.00 none none
in feet in feet in inches
18.GROUT
.............................
From To Material Emplacment Method&Amount
0.00 30.00 Concrete Mix and Pour(15 bags)
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
0.00 0.00 none none
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 75.00 red clay
in feet in feet
75.00 85.00 brown clay and rock
in feet in feet
85.00 92.00 brown rock
in feet in feet
92.00 118.00 gray rock
in feet in feet
118.00 130.00 dark gray rock
in feet in feet
130.00 305.00 gray and white rock
in feet in feet
21. Remarks
........ ......... ......... ......... .... ..... ......... ......... ......... ......... ......... ..... .... ......... ......... ......... ......... ........................... ...

none
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
.. ....................... ........................... ..................... ..............
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
Signature of Certified Well Contractor