GW1-2021-03144_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
I.Well Contractor Information:
James R.Wilson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 2404A ft. ft.ft. ft.
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NC Well Contractor Certification Number 1S OUTER.CASING for mult4cased wells OR LINER if al Ilcable
Wilson Well Drilling, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
0 ft• tat fL 1 6.25 I ;1"• SDR21 PVC
Company Name
W2020000547 16.INNER CASING OR TUBING(geothermal closed4000ll-
2.Well Construction Permit#: FROM TO DIAMETER1 THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1°
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural [3Municipal(Public fL ft. In.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) fk ft. trr
Industrial/Commercial EiResidential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ o fL _ zo ft. -Portland
- -- - _, ,.Gravity bags
Monitoring -- ---EIRecovery ---- - - It. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage & &
Experimental Technology 13 Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addidorialrheets If necessary)
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,solOrock eta
0 ft. 3 ft, Red Clay
4.Date Well(s)Completed:5-05-2021 Well ID#W2020000547 3 fk 154 fL Decomposed Rock
Sa.Well Location: 154 ft. 346 fL Granite'
Sherry Martin fL fL ,
Facility/Owner Name Facility It. ft.
ID#(if applicable)
d ".
Carson Lane, Murphy, NC 28906 ft. ft. i
Physical Address,City,and Zip ft. fL
Cherokee 448903410253000 _21.REMARxg
County Parcel Identification No.(PIN) -'^ ' L E'-;10"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) Certification:
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N W 5-05-2021
6.Is(are)the well(s)ox Permanent or Temporary Si turc of Certified Well Contractor Date
signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis 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 I 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: 346 (fk) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air/Rotary above,also submit one copy of Iliis?form within 30 days of completion of well
12.Well construction method: construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Utiderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 75 Method of test- Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
3o the address(es) above, also submitlone copy of this form within 30 days of
HTH Pellets
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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