GW1-2021-03152_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
James R.Wilson la:wATERzoNEs
Well Contractor Name _.�) Or FROM TO DESCRIPTION
fL ft.
NCWC 2404A b ,\J� {� {- ��
NC Well Contractor Certification Number 15.OUTER CASING for mnitl caeedllwells R LINER If a livable
Wilson Well Drilling, Inc. (t73�`O (���,rJr FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 1 123 ft. 6.25 [ in SDR21 PVC
022-1071 116.]NNTER CASING OR TUBING eothermai clowd-loatil
2.Well Construction Permit M FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural []Municipal/Public ft. fa In.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. % in.
Industrial/Commercial Residential Water Supply(shared) .18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ff _ 20 ft. Portland I Gravity-6 bags
Monitoring Recovery it ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PA ff. & if clivable CK
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage & ft.
Experimental Technology Subsidence Control & ft.
Geothermal(Closed Loop) []Tracer 200 DRILLING LOG attach addldonal sheets if necessary)
Geothermal(HeatingtCooling Return) nOther(explain under#21 Remarks) I FROM TO DESCRIPTION color,hardness set type,grain s1M etc
0 ft. a fL Red Clay
4.Date Well(s)Completed:5-25-2021 Well ID#022-1071 a ft* 116 ft
Sand Stone
Sa.Well Location: 116 & 1as fL Granite
Dylan Curtis fL ft.
Facility/Owner Name Facility ID#(if applicable)
Deerbrook Lane, Hayesville, NC 28904 ft. ft.
Physical Address,City,and Zip fL it. 1 1 N
CLAY 558003222375 2L REDLARKS UKJ
County Parcel Identification No.(PIN) f r,3t10
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 722cadon:
N W
5-25-2021
6.Is(are)the well(s)E Permanent or []Temporary S ture of Certified Well Contractor 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: []Yes or EX No with 15A 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 ofthe copy of this record has been provided to the well owner.
repair under#11 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.I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 166 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f di$erent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below to casing:50
P of g� (ft.) Division of Water Reso'urI s,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addit ion to sending the form to the address in 24a
12.Well construction method: Air/Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Air24c.For Water SuDDIv&Iniecti Wells: In addition to sending the form to
HTH Pellets 30 the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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