GW1-2021-01519_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: AT R S
1.(M'� -f FROM TO DESCRIPTION
CRANVAL D LEDFORD y f t^-1 89& 90 &
Well Contractor Name WA �11221t 123 ftNCWC4431-A 4 IOL1 5.0 R A ING for _.
ti` s O ,R��app'car e
NC Well Contractor Certification Number
intolrloatton processing Unit FROM To DIAMETER TI-uclQrEs MATERiAI,
CHEROKEE WELL DRILLING DWR Section 0 ft. 69 ft 6.125 In. SDR 21 PVC plastic
Company Name ft. & in.
6. R Cr1 ING O G(geotherma osed o0
2.Well Construction Permit#: 022-0974 FROM TO DIAMETER TFHCKNES MATERIAL
List all applicable well construction pertmits Oe County,State,Variance,etc ft. ft. in
3.Well Use: M ft. in.
7. EN
FROM TO DIAMETER nUCKNES4 SLOTS MATERIAL
Residential ft. fL in.
% ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft
it. fY.
& tI
/G C �f pp'car e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 2/25/2021 Well ID# tl. it.
it. it.
Sa. Well Location: 20DIGZ °-(attac tion ,s eets' �►ecessa -
List all applicable well construction pertmits(ze County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc)
KURT AND KATHY HEADLEY 0 it. 47 ft. Brown Slate
Facility/Owner Name Facility ID(if applicable) 47 ft 69 ft, Gray Hard Granite SET CASING
4102 DOWNINGS CREEK RD HAYESMLLE 28904 Lot 69% 89 it. Gray Hard Granite
Physical Address,City,and Zip 89 it. 90 it. Gray Fractured Granite FRACTURE 10 GPM
Clay 557100962504 90 it. 122 it. Gray Hard Granite
County Parcel Identification No.(PIN) 122 ft 123 ft Gray Fractured Granite FRACTURE 10 GPM
5b. Latitude and Longitude degreestminutes/seconds or decimal degrees: 123 it. 205 it. Gray Hard Granite
(If well field,one latAong is sufficient.) 1. $
35.076 N -83.75 W
6. Is(are)the well(s): Permanent
22. Ce 'fication:
7. Is this a repair to an existing well: No }� 3/3/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Si ontr or V ate
repair under#21 remarks section a on the back of this farm. By signing this form,l hereby certify that the wells) (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 of this record has been provided to the well owner.
For multiple iryection or non-water wells ONLY with the same 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: 205 (ft)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 1009 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
If water level is above casing,use"+" construction to the following:
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 Iniection 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): 20 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 Deoattment of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013