GW1-2022-08017_Well Construction - GW1_20220830

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1,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
15a n let O u rnrl-e rs 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
8.5 ft. 23.5 ft-
2579-A ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER'if a livable
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 8.5 1' 2 sch 40 pvc
Company Name .16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
rl Agricultural E]Municipal/Public 8.5 % 23.5 ft- 2 i" 010 sch 40 pvc
Geothermal(Heating/Cooling Supply) F1 Residential Water Supply(single) It. ft. in•
Q Industrial/Commercial E]Residential Water Supply(shared)'
18.`GROUT.
Irrigation
®Wells>100,000 GPD FR011r TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 4 ft portland mix&Pour
©X Monitoring Recovery 4 fL 6 ft- bentonite tremie
njection Well: ft. fL
Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery lJ Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 6 ft- 23.5 ft- 10/30 silica sand tremie
Experimental Technology Subsidence Control fL It.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUmck type,grain si etc)
0 ft 3 ft orange brown clay(moist)
4.Date Well(s)Completed:08-10-22 Well ID# MW-2 ft ft
3 23.5 red orange slightly sandy silt clay(moist-wet)
5a.Well Location: fL ft.
Former Markrs Exxon ft. ft - . �, f Vl N j
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
it
1055 Main St Bryson City, NC ft. ft.
Physical Address,City,and Zip ft. ft. InTG ii..1ti 071 r'i�C c'azi;;3 Unil
Swain 11.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certilication:
35.43211 N -83.43380 W o' 08-10-22
6.Is(are)the well(s):X©Permanent or O Temporary Signature oIrCertified"r Contractor Date
7.Is this a repair to an existing well Yes or No By signing this fonn,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
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 1 GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 23.5 (ft.)
For multiple wells list all depths if different(example-3 a 00'and 2@100') 24a. For All Wells: Submit this form Within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 17 (ft.)
1fuarer level is above casing,use"+•• Division of Water Resources,Information Processing Unit,
8-1 (in.)
Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Iniection Wells:In addition to sending the form to the address in 24a
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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& Iniection 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 Environmental Quality-Division of Water Resources Revised 6-6-2018