GW1-2021-03141_Well Construction - GW1_20210625

i ` V Frint Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
James Daniel Wilson 14.wATERzoNEs - -•
Well Contractor Name FROM TO I DESCRIPTION
NCWC 4303A ft fc
fL ft.
NC Well Contractor Certification Number
35:AUTER'CASING formuld-casedwells OR LINER ifa !!cable
Wilson Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft 1 43 f 1 6.25 SDR21 PVC
W2021000098 .M INNER CASING OR TQBING eothermsl closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.f/IC,County,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): & & in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SU E THICKNESS I MATERIAL
Agricultural 13Municipalftblic ft. % in.
Geothermal(Heating/Cooling Supply) 1311esidential Water Supply(single) It. & In.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - — -- -0--fL- —20 ft
Portland I Gravity-4 bags
Monitoring DRecovey ft. &
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
19 SAND/GRAVEL PACK a lleable -
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage & ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRUIMG LOG attach addidonal sheets if neces
Geothermal (Heating/Conlin Return Mother(explain under#21 Remarks FROM To DESCRIPTION color,hardy soturock etc.
0 fL 3 ft- Red Gay
4.Date Well(s)Completed:5-25-2021 Well ID#W2021000098 3 ft sand stone
5a.Well Location: s, fL 246 M Granite
Michael Borzych ft- It.
Facility/Owner Name Facility M#(if applicable) It. ft J IJ
Joe Brown Hwy, Murphy, NC 28906 fL ft.
r u+�gln. Ufi Il
Physical Address,City,and zip ft• ft Pl v1 n v 'All on
CHEROKEE 458300257818000
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in gi degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22. a Ica;!
N R' - -�� 5-25-2021
6.1s(are)the well(s)JOPermanent or Temporary Xg-mmgothis
f form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or %JNo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 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:' SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 246 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths J'doerent(example-3®200'and 2@100) construction to the following:
10.Static water level below top of casing:50 (ft.) Division of Water Reso I ces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 m, i
( ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air/Rotary above,also submit one copy of tfiis form within 30 days of completion of well
12.Well construction method: construction to the following:
I!
(i.e.auger,rotary,cable,direct pusb,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) 6 Method of test: Air 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
HTH Pellets the address(es) above, also submit'one copy of this form within 30 days of
3o
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016
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