GW1-2021-01516_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 4. AT ZO .
FROM TO DESCRIPTION
CRANVAL D LEDFORD 272 ft. 274 ft.
Well Contractor Name ft. ft.
NCWC4431-A5 UTE)2 GA G(fo u tI s ell O E _( ph e
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 90 fl- 6.125 in. SDR21 PVC plastic
Company Name ft. fL in.
6. jCA G O UB. (g e c o0
2.Well Construction Permit#: W2020000531 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction perimits(re County,State,Variance,etc ft. M in.
3.Well Use: ft. ft' in.
.7:S N
RECEIVED
FROM TO DIAMETER THICKNES SLOTS MATERIAL
v Residential ft. ft. in.
% ft. in.
Mlak X
Unit FROMrt TO MATERIAL EMPLACEMENT METHOD&AMOUNT
wormatton Processing 0 it. 20 ft
DWR Section ft. ft.
% ft.
9.S ,DIG L .11C (rf a p' e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
ft. ft.
4. Date Well(s)Completed: 2/4/2021 Well ID# TARHEEL N-TR 509 ft. ft.
5a. Well Location: 20, G OG attac ad do a eels ecessary
List all applicable well construction pertmits ft County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
JEFF GOOCH 0 ft. 68 ft. Brown Hard Slate
Facility/Owner Name Facility ID(if applicable) 68 ft. 89 ft. Gray Hard Granite SET CASING
150 TARHEEL WEST DR MURPHY 28906 Lot TARHEEL NORTH 89 R 272 ft. Gray Hard Granite
Physical Address,City,and Zip 272 ft. 274 ft. Gray Hard Granite FRACTURE 50 GPM
Cherokee 458216949250000 274 ft. 305 % Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft-
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21 S
35.08521 N -84.05072 W BIT SIZE 5.973
6. Is(are)theweil(s): Permanent
22. �fflcation:7. Is this a repair to an existing well: No 2/15/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Si Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form.I hereby certify that the wsll(s)um(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple ilecdon or non-water wells ONLY with the some construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 305 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If voter level is above casing,use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 Cm.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013