GW1-2022-08234_Well Construction - GW1_20220419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant RECEI `E D
14.WATER ZONES
Well Contractor Name n w ���n FROM TO DESCRIPTION
4328-B AP•• 1 6J L 30.2 f- 34 ft-
ft. ft.
NC Well Contractor Certification Number pfpr � V I5.OUTER CASING for multi cased'wells OR LINER iGa` lic961e «? j
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WM O 100510 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,Slate,Variance,etc.) 0 ft. 30 ft' 1 1.5 in. .25 1 Steel
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREENS
FROM TO DIAMETER SLOTSIZE THICKNESS V MATERIAL
__ Agricultural ®Municipal/Public 30 fL 34 ft- .75 in- .004 .25 Stainless
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
__ Industrial/Commercial 13 Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
X Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if.a licable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology rISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets ifiiieessa "
Geothermal(Heating/Cooling Return) 1-Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION color,hardness,soil/rock type,grain size etc.
4.Date Well(s)Completed:4-1 1-22 Well ID#MW-2 ft. ft.
5a.Well Location: ft. ft.
Parks Hospitality Group ft. ft.
Facility/Owner Name Facility ID#(i£applicable) ft. ft.
59 Depot Street, Waynesville, 28786 ft. ft.
Physical Address,City,and Zip ft. ft.
Haywood 21.REMARKS
County Parcel Identification No.(PIN) Tempprary we".
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22.Certification:
35.492342 N 82.988234 W 926!2: i 4-13-22
6.Is(are)the well(s)13Permanent or JBTemporary SigMurc-6f'Ccriifi6d We Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or gNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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:Ono (1) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diereni(example-3 a 200'and 2@100') construction to the following:
30.21
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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