GW1-2022-08233_Well Construction - GW1_20220419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
:;_
Well Contractor Name FROM TO DESCRIPTION
4328-B 24.5 ft. 28 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for'malti cased'wells OR`LINER'ifa" licablex
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
WM0100510 16.INNER CASING OR TUBING eothermal.closed ldi"
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable wel/construction permits(i.e.U1C,County,State,Variance,etc.) 0 ft 24 fL 1.5 1° .25 Steel
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 24 It. 28 ft 75 in. .004 .25 Stainless
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
__ Industrial/Commercial QResidential Water Supply(shared) 18.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-Water Supply Well: ft. ft.
onitoring _ DRecovery ft. ft.
ction Well: ft. ft.
Recharge Groundwater Remediation19-SAND/GRAVELPACK ifa licablequifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHODquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG.attach additional sheets if:necessii`"
_ Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:4-1 1-22 Well ID#MW-3 ft. ft.
5a.Well Location: ft. ft.
Parks Hospitality Group ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ArR
59 Depot Street, Waynesville, 28786 ft rt. pmcewing
ROG
Physical Address,City,and Zip ft. ft. (�1
Haywood 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:
35.492560 N 82.988175 W
4-13-22
6.Is(are)the well(s)oPermanent or laTemporary Si&turK5rCertdWd W&I Contractor Date
By.signing this form,t hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known we/l 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:Ona (1) SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 28 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:24.59 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.511 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
12.Well 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 WELLS 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
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 2-22-2016
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