GW1-2021-03143_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James Daniel Wilson :14.WATER ZONES
Well Contractor Name FROM To I DESCRIPTION V
NCWC 4303A It. fL
I i
NC Well Contractor Certification Number It. fL f I
-15:OUTER CASING for muld-cased wells OR LINER lta ilcabie
Wilson Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft 30 ft 6.25 in SDR21 I PVC
W2021 000187 16.INNER CASING OR TUBING eothermal closed-Inaill
2.Well Construction Permit#: FROM To DIAMETER 1 THICKNESS I MATERiAI, J
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17:SCREEN -
A Cnitulal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
13Municipal/Public ft ft.
RGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT '
Inigati. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:_ ._-- ---- —� _ _ --
._0_ ft-—Y0. ft. Portland i Gravity-4 bags - - _--- ---- --
Monitoring ORcoovery It. ft.
Injection Well:
Aquifer Recharge E3Groundwater Remediation ft. ft.
ff
Aquifer Storage and Recovery []Salinity Barrier 199.OSAND/GRAD L PACK MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Traeer 20.DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION color,hanhi sowrock etc
0 ft- 3 fL Red Gay
4.Date Well(s)Completed:5-21-2021 Well ID#W2021000187 3 ft. 22 ft. Sand Stone �
Sa.Well Location: m ft. 106 fL Granite'
Kevin Woodring ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. •�
60 Kilby Rd.Murphy, NC 28906 It. ft. CL,-gtCt
Physical Address,City,and Zip ft. ft. CJB�t,M.
Cherokee 456600747650000 21.REMARK _r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is sufficient) 21.Ce 'reatioa:
N R' 5-21-2021
6.Is(are)the well(s)ox Permanent or OTemporary tore of Certifi ntractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or XINo with 15A NCAC 02C.0100 or 1 SA 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:
S.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
9.Total well depth below land surface: 106 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3Q200'and 2Q100�
construction to the following: `
10.Static water level below top of casing:30 (ft) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) t 6
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air/Rotary above,also submit one copy of tlu's!form within 30 days of the
of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
(`
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: Air 24c.For Water Suooly&Iniect`o»Wells: In addition to sending the form to
the address(es) above also submit lone copy of this form within 30 days of
13b.Disinfection type: HTH Pellets Amount: 30 completion of well construction to the cooty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016