GW1-2021-00435_Well Construction - GW1_20210201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.%ell Contractor Information:
Terry White 14.WATER ZONES `
IRON TO 1a
DESCRIPTION
well Cm Name
3287-B s fL fL
fL ft.
NC Well Commuter Certification Number IS OUTER CASING f-7! eared wdY OR WNER
ETFROM TO DLAME ER THICKNESS MATERIAL
R ft. is
Company Name tfi.INNER CASING OR
7 I 'G
ETER THICKNESS
2.Well Construction Permit H: FROM TO DUM MATER.1.
I;�uall"PI'l bla"it"hoev"naPermroM1e-rile.many.ware. Iananeeere) 0 rL 4 FL 2 is SCh40 PVC
3.W'ell Use(check well use): h. ft. in.
Water Supply Well: IZ SCREEN
FROM TO DIAMETER SWTSIZE THICKNESS MATERAL
Agricultural E)Mumcipal/Public 4 't 14 ft 2 la' 0.010 SC1140 PVC
Geothermal(Ilcating/Coohng Supply) Residential Water Supply(single) h I a in.
Industrial/Commercial Residential Water Supply(shared) II GROUT
hie atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 fL 3 IL Bentonite Poured/25LB
Monitoring oRcenvery 0 R 2 IL Cement Poured/501-b
Injection Well:
rt rL
Aquifer Recharge OGroundwater Remechimon 19.SANWGRAVLL PACK Iif
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPIACEMEW METHOD
Aquifer Test E]Slonowater Drainage 3 ft 14 h• #2 Sand Poured
Expenmental Technology Subsidence Control ft &
Geolhermal(Closed Loop) OTracer M DRILLING LOG Iaroreh ii"deaY shxbB
mom TO DESt7itne ON wMr harYww,mikrarkt me.eta.
Geothermal(Heating/Cooling Return) Other(explain under 921 Remarks) ft It See Consultant Log
4.Date Wells)Completed: 1/27/2021 Well ID#M W-6 ft. R'
Se.Well Location: rL ft.
BP Gas Station ft. ft.
Fsedm Owner Name Facility IDO(ifapplicablc) IL ft 1
5171 Jonathan Creek Rd. Waynesville 28785 rL ft
Physical Address,City.and Zip ft ft
Haywood 21•REMARKS
Co.[, Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
11'well field one lat/loog is Sufficient) 22.Certification:
35 35 38.30 N 83031.40 W. 1/28/2021
6.Is(are)the well(s)Mr Permanent or ❑Temporary Signature 'erufied Well Contractor Dam
8, sigrnng rhos/on, 1 hereh,c,roh-rhar the wellpy vas rnerer camnrued,n...cvrdasre
7.Is this a repair to an existing well: Yes or OR No u ah 15A V A( 02('.0100 nr 15.4 V:a( 02( 0200 H'efi r'unanr</.. nd rhar o
/Rho is o repo,,,fill om brown well ronnn cnnn of on,oeo aml a-rP(am the nature of the .,y, ,f h,,record hon hren mend.d ro ilia.ell.......
repay muter-21 remnrkemcnon or un the hark f rhos ft rm.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
1.,r mutrrple we7Lr llsr all Aeprhs Jdgerem/ample-3(a 200'and21a100') construction to the following.
10.Static water level below top of easing:5 (ft) Division of Water Resources,Information Processing Unit,
/jwmerle,e!ra above ear;....s.- 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
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following.
u.e.auger.rotary,cable,direct push.ac)
Division of Water Resources,IToderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a,Yield(gpm) Method of test: 24c. For Water Supply& Infection 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: Amount: completion of well construction to the county health department of the county
where constructed-
Form GW-I North Carolina Department of Eannonme tal Quahry-Dn ision of Water Resources Revised 2-22-2016