GW1-2021-00242_Well Construction - GW1_20210123

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form an be used for single or mttiple wells
1.We6 Contractor Information: ...
FROM TO DESCRIPTION
CRANVAL D LEDFORD 340 R 341 ft
Well Contractor Name 480R 481 ft.
NCWC4431-A I&OUTERCASM(fornawA&Wells
NC Well Contractor Certification Number FROM TO DIAM1 EiM _ MATERIAL
CHEROKEE WELL DRILLING 0 8. 49 fL 6.13 hL SDR 21 PVC plastic
Company Name R R In.
16.INNER CASING OR TUBING(geode
2.WeB Construction Permit#: W2020D00449 2020000448 FROM TO DIAMETER---- IMCKM33 MATERIAL
Lai all aWwable vdi consintcaon patine;#a County.Scar, Farimsia,et R IL in.
3.Well Use: ft B. in.
17.SCREEN
FR0A1 I I)1AA1LIb1, TIIICKNFS SLOTS MATERIAL
Residential fl. fl. in.
fl. ft. fa
CROUT
FROM '1'0 MATERIAL Fh1P1.AC@•d@iT MH1HOD d:AMOUNT
1 D R 20 R ldenm
ft fL
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
IROM 'I'o MATERIAL EMPLACEWNT AIE-THOD&AMOIIN
ft. ft.
ft. ft
4. Date WeR(s)Completed: 12/19/202D Well WO WELL I -LOT IA R ft.
Sa. Well Location: �,ING LOG< uaeceaary)
Lit a9 applicable well construenon persists 0e County,Slate.karimre.ex, FROM TO DESCRIPTION(color,hardiest soiVrock type,grain size,etc)
SGAP LLC LOT 1-A 0 R 27 ft Red Slate
Facility/Owner Name Facility ID(if applicable) 27 It. 49 fit Gray Granite SET CASING
NUGENT LN MURPHY 28906 Lot 1A MWASSEE CREEK ESTATES 49 a 340 d Grey Granite
Physical Address.City,and zip 3401L 341 IL Gray Fractured Granite WATER ZONE 5 GPM
Cherokee 45610018398DODO 341 1L 480 ft. Gray Hard Granite
County Pa¢el Identification No.(PrN) 480 tL 481 R Gray Fractured Granite WATER ZONE 15 GPM
Sb. Latitude and Longitude degrees/mnutestseconds or decimal degrees: 481 ft. 505 B. Gray Hard Grande
(Ifwe9 field,,,, 21.REMARKS Wx=
35.06651 N -84-14293 W
Q Is(are)the well(s): Permanent
I2.�flmflon:7. Is this a repair to an existing well: No 1/18/2021Iftks a arepr fill out knownveil ontrmaaaat it formason aM explain the.careofdar Sacmr Dete
repair under a 21 remarks section or on the back of tier form. By signrtg this form I hereby armfy that the ire/l(s)was(were)cnnarructed m accordance
with 15A NCAC 02C.01M or ISA NCAC 02C.0200 Weil Corot mon Sumdmds and.hota
S. Number of wellsoonstracted: 1 copy oldies record ham been prusided0 the wit carter.
For multiple uyecaon or an-later It,ONLY with the same mnrmuctim yam can 23. Site diagram or additional well details:
submit ore farm You may use the back of this page to provide additional well site details or well
�1 � construction
details. You may also attach additional pages if neceary.
9.Total well depth below land am face: 505 � 'nil. •
For multiple weltslist all depths jd$eren m(einpk-3Q 200'and 2@10) w\ Y SUM]TTAL INSTRUCTIONS
�P 10.Static water level below top of acing: 120 24s.For AB Wells: Submit this form within 30 days of completion of well
(ft.)
Ifwater keel is abuse casing,use"+^ construction to the following:
Division of Water Quality,Informatlaa Procession Unit,
11. Borehole diameter: 6 (bL) 1617 Mall Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 241.For Infection Wells: N addtim to sendingthe form to the address in 24a
lie.auger,rotary,cable,direct pusk e¢.) 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 Qua a Quality,Undergron Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Srmaly ledeclion 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: conpletion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Derartrnmt of Environment and Natural Resources - Division of Water Owl" Revised Jan 2013