GW1-2022-08018_Well Construction - GW1_20220830

Print Form WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1.Well Contractor Information:
banieIS-6m"_ lers 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
8 ft 18 ft.
2579-A
ft ft
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER if a lic9ble
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 8 ft 2 in• sch 40 PVC
16.INNER CASING OR TUBING eothermal closed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS NATERIAL
Q Agricultural I!�Municipal/Public 8 ft 18 ft 2 in. 010 sch 40 PVC
®Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft ft. in.
©Industrial/Commercial ®Residential Water Supply(shared) 18.
GROUT
Irrigation Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 4 ft portland mix&Pour
Monitoring Recovery 4 ft 6 ft bentonite tremie
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL:PAC K if a licahle
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 6 ft 18 It, 10/30 silica sand tremie
Experimental Technology i Subsidence Control ft ft
Geothermal(Closed Loop) Q Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) FROM To DESCRIPTION color,hardness,soil/rock tv a rain sire etc.
( g/ g ) �Other(explain under#21 Remarks)
0 ft 3 ft orange brown clay
4.Date Well(s)Completed:08-10-22 Well ID# MW-1 ft ft
3 18 red orange slightly sandy silt clay(moist-wet)
5a.Well Location: ft ft
Former Mark's Exxon ft ft _
Facility/Owner Name Facility ID#(ifapplicable) -T
ft ft
1055 Main St Bryson City, NC rt ft
Physical Address,City,and Zip
ft ft
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: /)
35.43220 N -83.43354 W 08-10-22
6.Is(are)the well(s):X®Permanent or ®Temporary Signature of Certified V 41 Contractor Date
7.Is this a repair to an existing well ®Yes or® No By signing this form,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 die copy of this record has been provided to fire 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: 18 (ft.)
For multiple wells list all depths ifdifferent(erample-3 rr 00'and 2@I00') 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: dry
If water level is above casing,use"+" Division of Water Resources,Information Processing Unit,
8„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Infection 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