GW1-2021-00439_Well Construction - GW1_20210201

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White IL WATER ZONES
Well Comer.,Name FROM TO DESCRIPTION
is
3287-B s ft.
It ft.
NC Well Contractor Certification Number IS.OUTERCASI for NG adti-eY1!d web OR LINER
ETFROM TO DAMETER THICKNESS MATERIAL
R R in
Company Name IC INNER CASING OR TURRfG r
2.W'ell Construction Permit N: FROM TO DIAMETER THICKNESS MATERIAL
Lis,all eppGmble hell constrnamn permlrs(Le.ULC,C'ouno' Stare, Varianoe,rla) 0 R 4 FL 2 1O' Sch40 PVC
3.Well Use(check well use): R ft. rrt
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public 4 R 14 R 2 '°' 0.010 s&O PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. I fL in.
Industrial/Commercial Residential Water Supply(shared) 11GROUT
—liffigation FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 2 D. 3 R- Bentonite Poured/25LB
Monitoring Recovery 0 R 2 IL Cement Poured/501-b
Injection Well:
fL IL
Aquifer Recharge OGroun lwater Retied anon 19 SAND/GRAVEL PACK R
Aquifer Storage and Recovery OSalmay Bartier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OSlonnwater Drainage 3 fL 14 R. #2 8a0d POUfed
Expenmental Technology OSubsidence Control R rL
Geothermal(Closed Loop) OTmcer 20.DRILLING LOG IapaeIt additional sheebB
Geothermal(Heating/Coolfng Remm) r3Other(explain under 821 Remarks) FROM TO DESCRIPTION e.lur,metineea,a.iVrvck t,ie,tiona sate.et..
R n- See Consultant Log
4.Date Wells)Completed: 1/27/2021 Well ItW M W-7 R D.
R R
Sa.Well Location:
BP Gas Station fL fL
Facility,/Owner Name F.e.lity me Ifappinable) Ft, (t.
5171 Jonathan Creek Rd. Waynesville 28785 fL ft, Nil
Physical Address,City and Zip fL fL r
Haywood 21.REMARKS
Count, Parcel Identification No (PIN)
5b.Latitude and longitude In degrees/minute3/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
35 35 38.30 83031.40
" W %at,2u_ GtJ![� 1/28/2021
6.Is(are)the well(s)Of Permanent or OTemporary rnounme Vuenified Well Contractor Date
B, sign....,his form,I hereby tend'shot the well(/eras(war c netructed or accnrdu..re
7.Is this a repair to an existing well: Oyes or O% No .mh 15A NCAC 02'-0/00 ar 15A NOR 0A 0200 Well( Srandmd.and.bar a
1fda,o a repair fill at known.ell ca..orn,rton.n(aroad on and espuma dre rmmre of rite cupy of aho retard has heen prnc.ded m rLe xell a..er.
repair under all remarks section or on the back of this f rns.
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: 14 (pi-) 24s. For All Wells: Submit this form within 30 days of completion of Well
l�rmu0iplewe/ls baral/depths fdge..in(va,,ple-3(&200'and 2(pd100') construction to the following:
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
Lfwmer/erel.shove vs.ng.use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Au above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Auger construction to the following:
It e-auger,rotary,cable,dimct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13%Yield(gpm) Method of test: 24c.For Water Supply& Injection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department of 8&nirnnmental Quality-Division of Water Resources Revised 2-22-2016