GW1-2021-00438_Well Construction - GW1_20210201

PdiIE E XM
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.'A ell Contractor Information:
Terry White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name rJ (t 14 ft.
3287-B
ft ft.
NC Well Contractor Certification Number IS.OUTER CASING for tulti-rued wd6 OR LINER
ETFROM TO DL\METER THICKNESS MATERIAL
R ft. a
Company Name Ib.INNER CASING OR TUBING r7rerd-Ito
2.W'ell Construction Permit k: Mom TO DAMETER THICKNESS MATERIAL
1tv a0 applicable well e.nstruetton permit,it-1/1l' County,stare, Cari.nce.etc-) 0 IL 4 n- 2 in. I Seh40 PVC
J.Act[Use(check well use): IL R. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public 4 fL 14 It 2 in. 0.010 SCh40 PVC
Geothermal(Heating/Cording Supply) [)Residential Water Supply(single) IL n,
Industrial/Commercial [)Residential Water Supply(shared) I&GROUT
Irri alion FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft 3 It Bentonite Poured/25LB
Monitoring ORecovery p It 2 It Cement Poured/501-b
Injection Well:
ft ft
Aquifer Recharge [)Groundwater Remediation
U.SAND/GR PACK H
Aquifer Storage and Recovery [)Salinity Barrier PROM TO TO MATERIAL EMPLACEMENT METHOD
Aquifer'fest [)Stonnwater Drainage 3 IL 14 R• #2 Sand Poured
Experimental'I'echnology [)Subsidence Control ft. ft
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG humach addidaaY sheebl
Geothermal(Heating/Cooling Return) r30ther(explain under#21 Remarks) Mom TO DESCRIPTON valor.bandana,iaumri,ni tir vu,en.
ft ft See Consultant Log
4.Date Well(s)Completed: 1/26/2021 Well IDe M W-5 m ft.
IL ft
5a.Well Location:
BP Gas Station fL ft.
Facility/Owner Name Facility lDd(if applicable) ft H.
5171 Jonathan Creek Rd. Waynesville 28785 n, ft. 1
Physical Address,City,and Zip ft R
Haywood 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iavlong is sufficien) 22.Certification:
35 35 38.30 N 83031.40 W,
/oytieu_ G{Jlief 1/28/2021
6.Is(are)the well(s)o% Permanent or [)Temporary Signature eCernfied Well Contactor Date
8, .igning,h,,form, I hereAv ,,1 fi that the well(s)a-as(arre/mrranreted m accord.....
7,Is this a repair loan existing well: [)Yes or %[)No a oli 15,4 NCAC 01" U100 or 15A NG4C 011' 02011 Well Conurimtion Smndarda.nd Ihal a
If rhtx is a repaiq,fill our known aell construction mf.rmarlan and esplam the�mrc•r,f the .vpv Jthn record has been pr.mded to the..ell parer.
repair under !1[remmkssection or on the Aa.k of thin j nn-
23.Site diagram or additional well details:
S.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 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formrdaplewellr hotilldepoeard/jjerent/exatnpk-3@200'and 21&100') construction to the following:
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
[fw.ter level t.oh.vo eo:gag,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 (in.) 24b.For Infection Wells: In addition to sending the forth to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.W<II construction method: construction to the following:
(i e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a-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
13h.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carob.Department of Eneimnmenal Quality-Division of Water Resources Revised 2-22-2016