GW1-2022-01081_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-01081
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Email Address*
Contact Name* haley.thompson@byerswelldrilling
Haley Thompson com
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
3131 A LON DILLARD BYERS WELL DRILLING, INC.
2.Well Construction Permit#:
.....................................................................................................
022-1024
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

12/15/2021 100
(gallons per minute)"
5.Well Location
Facility/Owner Name* Facility ID#
Michael J. Layton
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Clay 640800589497
Physical Address* Street Address
94 Sally Gap Trail
Address Line 2
City State/Province/Region
Hayesville INC
Postal/Zip Code Country
28904 USA
Latitude* 35.0007200000 Longitude*83.3922400000
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.)
245 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
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)
100 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:
Chlorine 20 oz

14.WATER BEARING/FRACTURE ZONES
From To Description
0 130 >1 GPM
in feet in feet
130 245 100 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
.......................................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 20.00 Cement Gravity
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
in feet in feet
21. Remarks
Drilled existing well deeper by 115'.Well was originally 130'deep.We drilled from 130'to 245'and got 100+GPM.
22.Site diagram or additional well details:
You may upload additional well construction information here.
NC Sally Gap Hayesville-Mike Layton-Well Permit.pdf 1.81 MB
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
ff 4?2a1 1
Signature of Certified Well Contractor

CLAY COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH DIVISION
PO BOX 55 -- HAYESVILLE, NC 28904
PHONE [phone] FAX [phone]
COUNTY WELL PERMIT #:
022-1024
PAGE # 1
PERMIT TO CONSTRUCT OR REPAIR PRIVATE DRINKING WATER WELL
NEW:
REPAIR:
ISSUED TO: J. Michael Layton
PROPERTY 94 Sally Gap Trail
LOCATION:
SUBDIVISION: n/a
x
VARIANCE:
x
ABANDONMENT:
Parcel # 640800589497
TYPE OF STRUCTURE AND/OR FACILITY SERVED: Single Family Home/ Residence
WELL CLASSIFICATION: Single Family Home/Residence
CONDITIONS:
• Follow conditions listed in Variance Approval No. JMB2172 (attached to well permit).
• Permit to REPAIR EXISITING WELL- DRILL DEEPER ONLY.
• Well head must be brought up to current well head completion standards:
• Well tag with new well information
• Pump tag
• Vent cap
• Sealed electrical port
• Threadless sampling tap
• Well casing must be a min of 12" above land surface- even if using pitless adapter
• Must call ENV OFFICE in advance to schedule grout inspection.
• Well grouting shall comply with 15A NCAC 02c.0107 (e) Allowable Grouts & (f) Grout
emplacements.
This permit is valid for a period of five years from the date of issuance except that it may be revoked at any time if it is
determined that there has been a material change in any fact or circumstance upon which the permit was issued. Well location,
installation, and protection shall meet all state rules and regulations. Well water quality and yield, during the entire life service of
the well, is NOT guaranteed by the issuance of this permit, Clay County Health Department, and the State of North Carolina.
Amb
ORIZEp STATE A
Jones RtHS1l#2747
REVISED 07/03/17

CLAY COUNTY HEALTH L,.PARTMENT
ENVIRONMENTAL HEALTH DIVISION
PO BOX 55 -- HAYESVILLE, NC 28904
PHONE [phone] FAX [phone]
Clay County Web Map
SITE PLAN
COUNTY WELL PERMIT #:
022-1024
PAGE # 2 --CONTINUED--
1:1,128
o 0.01 0.02
0 0.02 0.04
NC CGIA, GeoEye, Maxar, Microsoft
0.04 mi
0.07 km
Owner: J. Micheal Layton
Pin: 640800589497

CLAY COUNTY HEALTH D,,r'ARTMENT
ENVIRONMENTAL HEALTH DIVISION
PO BOX 55 -- HAYESVILLE, NC 28904
PHONE [phone] FAX [phone]
WELL INSPECTION RECORD:
❑Grouting inspection OR ❑self -certified by well contractor:
Date:
EHS:
❑ Yes 0 No - Top of casing at least 12" above land
surface?
❑ Yes 0 No - Grout to land surface?
❑ Yes 0 No - Watertight pipe and electrical entry?
❑ Yes 0 No - Half inch access port with vent?
❑ Yes 0 No - Watertight well seal or cap?
❑ Yes 0 No - Threadless sampling tap?
❑ Yes 0 No — Pitless Adapter?
❑ Yes 0 No - Well contractor ID plate?
❑ Yes 0 No - Pump Installer ID plate?
❑ Yes 0 No - Copy of GW-la?
Water Samples Collected:
Date:
COUNTY WELL PERMIT #:
022-1024
PAGE # 3
--CONTINUED--
Type of grout used
Method of Grout
emplacement
Number of Bags used for
grout
EHS:
Well Head Inspection: Comments, Corrections, Dates:
Attached Well or Site Information
CERTIFICATE OF COMPLETION
The well owner shall place potential sources of groundwater contamination closer to the well than the separation distances
specified in 15A NCAC 2C. This well was constructed according to the well construction permit and the State of North
Carolina Private Drinking Water Well Rules.
AUTHORIZED STATE AGENT
DATE

NC DEPARTMENT OF
HEALTH AND
HUMAN SERVICES
J. Michael Layton
2635 N. Narcoossee Rd
St. Cloud, FL 34771
ROY COOPER • Governor
MANDY COHEN, MD, MPH • Secretary
MARK T. BENTON • Assistant Secretary for Public Health
Division of Public Health
Onsite Water Protection Branch
November 30, 2020
Re: Approval No. JMB2172
Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C
.0107(a)(2)(P)]
Property location:
94 Sally Gap Trail
Hayesville, NC 28904
Dear Mr. Layton;
On November 30, 2020 the On -site Water Protection Branch received your request for a
variance from the Well Construction standards, Title 15A North Carolina Administrative
Code Subchapter 2C .0100. The request for the variance concerns a water supply well on
the referenced property that is serving one dwelling. The well is in need of a repair and
there is a structure within twenty five feet of the well.
Specifically, the variance request grants you permission to use a water supply well at a
distance closer than the twenty five foot setback to a building perimeter. Achieving the
twenty-five foot setback would be difficult given the challenges of the property.
Based upon information provided by you, the Clay County Health Department, it is
my finding that based upon current conditions as the site exist today (as well as the
current proposal for use of the structure) you meet the conditions necessary for
approval of a variance as specified by 15A NCAC .0118 (a) (1) and (2). On that basis
and if the following conditions are met, the requested variance is approved:
1) The well/wellhead shall meet all current 2C. 0100 standards, including but not limited
to being properly grouted, terminated at least 12" above land surface, properly
sealed, and having a thread -less sample tap etc.
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH
LOCATION: 5605 SIX FORKS RD, RALEIGH NC 27609
MAILING ADDRESS: 1632 MAIL SERVICE CENTER, RALEIGH NC 27699-1632
www.ncdhhs.gov • TEL: [phone] • FAX: [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

2) The well shall be sampled for the same parameters required of a newly constructed
well. If samples indicate contamination, further repairs or treatment will be
necessary.
3) No potential sources of groundwater contamination shall be stored near the well -head.
4) A repair permit must be obtained from the Clay County Health Department before
work can begin on the well repair.
The granting of this variance is for the well location only. It in no way relieves the owner
or agent from other requirements of the North Carolina Well Construction Standards
including, but not limited to the requirements in 15A NCAC 2C .0113(b) to repair or to
abandon any well which acts as a source or channel for the migration of contamination.
This approval does not imply sufficient water quality. Further, the approval does not
relieve your responsibility to comply with any other applicable Federal, State, or local
laws or regulations.
If you have any questions regarding this variance, please contact me at [phone].
Sincerely,
John M. Brooks R.E.H.S, MS
2