GW1-2021-01517_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
O, 14.WATER ZONES
1.Well Contractor Information: a t-»
FROM TO DESCRIPTION
CRANVAL D LEDFORD 151 ft. 152 ft.
Well Contractor Name ft. ft.
NCWC4431-A information lirocessing Unit 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)_
NC Well Contractor Certification Number DWR Section FROM TO DIAMETER THICKNES4 MATERIAL
CHEROKEE WELL DRILLING 0 ft. 88ff- 6.125 in- SDR21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2021000017 FROM TO DIAMETER THICKNESE MATERIAL
List all applicable well construction pertmits lie County,State,Variance,etc. ft ft. in.
3.Well Use: ft ft. in.
1.7.SCREEN
:i
FROM TO DIAMETER THICKNES SLOT S14 MATERIAL
Residential ft ft in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft it ntoni
ft ft. •epipe
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 2/10/2021 Well ID#
ft. ft.
Sa. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits lie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
MICHAEL QUINN 0 ft. 6 ft. Soft Topsoil
Facility/Owner Name Facility ID(if applicable) 6 ft. 71 ft. Brown Hard Slate
2200 HIWASSEE DAM ACCESS RD MURPHY 28906 Lot 71 ft. 87 ft. Gray Hard Granite SET CASING
Physical Address,City,and Zip 87 ft. 151 ft. Gray Hard Granite
Cherokee 454400424436000 151 ft. 152 ft. Gray Hard Granite FRACTURE 40 GPM
County Parcel Identification No.(PIN) 152 ft. 205 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21.REMARKS
35.12847 N -84.20148 W BIT SIZE 5.913
6. Is(are)the weli(s): Permanent
22. ertification:
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 of the Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back of this form. 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
8. Number of wells Constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit oneform. 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: 205 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection 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): 40 Method of test: Air 24c.For Water Supply lniection 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.
Fonn GW-1 North Carolina Deoartrnent of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013