GW1-2021-00437_Well Construction - GW1_20210201

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
1.%ell Contractor Information:
Terry White I/WATERZONES _
Nell Coaoneva Name (ROM TO PI'I DEsTa1ON
3287-B 5 R 12 ft
It ft.
\C Well Cormetor Cenification Nnmber 15.OUTER CASING for adSrwrrd wdla OR LINER f
IETFROM TO DIxMETER THICKNESS MATERIAL
ft ft. is
Company Name
16 INNER CASING OR TUBING cool lfaeadJaa
2.K'ell Construction Permit N: FROM TO DLAMETER THICKNESS MATERIAL
Losta/l app/icuhlc un//consrrucuan permm lo.e. ll[C,County.&are. Lbnance.ercl 0 !° 4 ft 2 in' Sch40 PVC
3.Well Use(check well use): (t Et in,
Water Supply Well: 17•SCREEN
FROM I TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 4 fL 12 ft 2 i°' 0.010 SCh40 PVC
Geothermal(I lealmis/Cooling Supply) Residential Water Supply(single) a (L His.
Industrial/Commercial Residential Water Supply(shared) IE.GROUT
IRK anon PROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Rater Supply Well: 2 R, 3 H, Bentonite Poured/25LB
Monitoring DRecovery 0 (L 2 IL Cement Poured/501-b
Injection Well:
ft R
Aquifer Recharge OGroundwaler Remedimion 19.SAND/GRAVEL PACK R
Aquifer Storage and Recoeen OSalinity Banner mom TO MATERIAL EMPLACEMENTMEfHOD
Aquifer Test �SnuTnwater Drainage 3 0. 12 R• #2 Sand Poured
Experimental'Technology OSubsidence Control !t h
:)Geothermal(Closed Loop) 07'racer 20.DRILLING LOG amrb dada"rbu"H
ilhok r�br. » aa.as.
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION hardnm,Other(explain under N21 Remarks) ft IL See Consultant Log
4.Date Wellls)Completed: 1/26/2021 Well IDNMW-3 ft R.
Sa.Well Location: (t f.
BP Gas Station ft ft
Facility'Owner Now Facility lDa l ifapplicable) ft R.
5171 Jonathan Creek Rd. Waynesville 28785 ft ft
Phyvcal Address,City,and Zip ft ft
Haywood 21.REMARKS
Couno Parcel Identification No.(PIN)
Sb,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laolong is sufficient) 22.Certification:
35 35 38.30 N 83031.40 W. 1/28/2021
6.Is(are)the well(s)OPermanent or QTemporary Signamm r
:eddied Well Contmelor Date
In mgrrmg rhos krrm,/herehv cern(i rhar in,wvlllr/wa.Iwerer con.rnmrrAm aarordance
7.Is this a repair to an existing well: oves or %JNU e,,h/SA S('A('02('.0100 ar ZSA MCA('02( .0200 H'e/l('rrnoreo o SlondarJ.mid rhar o
/Jlho.rs a rcpay.fill ouI knm n v-ell c .rnommn o,ornrmuw mAezp/tun rho rrmurc nf1he ,,of,h..record ha,heen prnrideJ i o tar well owner
repair under=21 remurkr see non or on the hat k njrhisJona 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Clo td-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 com'truclion details. You may also attach additional pages ifnecessary.
drilled.one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Phi mrdnple wvlL.bvl oil depths jdg rem/e*.aniple-3(a�11N1'and 2(r2100') construction to the following'.
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
gwmer Ieve/t.'hare vaxmg,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
Auger above. also submit one copy of this form within 30 days of completion of well
i e Well construction method: construction to the following
i .e.auger,rosary,cable,dircc[push,etc 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Injection 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 couniv health department of the county
where constructed.
Fonn G W-1 North Carolina Department Of ETAIroomened Quality-Division of Water Resources Revised 2-22-2016