GW1-2021-03295_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
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1.Well Contractor Information:
FROM TO DESCRIPTION
CRANVAL D LEDFORD 170 ft. 171 fL
Well Contractor Name
NCWC4431-A 5 0_IJI)uRCASING farmulti°case�w _(w _ '�eDs)ORI��IlVER(ifsapp cblc)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES 4 MATERIAL
CHEROKEE WELL DRILLING 0 fL 128 fL 6.125 in. SDR 21 PVC plastic
Company Name ft. R' HL
ItS:' R.CA IN OOR �UBIN_G thermal COO Loop F
2.Well Construction Permit#: W2020000456 FROM TO DIAMETER t THICKNES4 MATERIAL 3
List all applicable well construction pertmits he County,State, Variance,etc iL fL in,
3.Well Use: ft. fL im
FROM TO DIAMETER THICK NES SLOTS MATERIAL
Residential ft. fL in
ft. ft. in.
28.�GT2�QITT��FROM TO K MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft
iL ft.
ft. &
119 SAN_ D/ RtlLPACK(#fa_pcable} � �
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
ft. ft.
4. Date Well(s)Completed: 5/20/2020 Well ID#
ft. ft.
5a. Well Location:
List all applicable well construction perbnits Cie County State,Variance,etc. 20a��ILLIN�OG�( -h�ad��df�o�nafi�ts.dme�""ssary�p�� -� - ,.
KENNETHPIERSON FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
0 fL 90 % Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 90& 128 fL Gray Hard Granite SET CASING
7430 HWY 294 MURPHY 28906 Lot 128 fL 170 ft. Gray Hard Granite
Physical Address,City,and Zip 170% 171 ft. FRACTURE 5 GP qa
Cherokee 453300929713000 171 ft. 305 % Gray Hard Granite
County Parcel Identification No.(PIN) % fL I I'
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft. J U N X 2021
(If well field,one lat/long is sufficient.) �P ,���� pf
1,�2EMA12KS:��, �;
`� ir�f.,fm� �rr�'P�c�sstrag�U�tl$ ..:
35.10173 N -84.218741 W BIT SIZE 5.929" DVVR Section
6. Is(are)the well(s): Permanent
22. cation:
7. Is this a repair to an existing well: No 440� 5/21/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified ell Pontraw/r Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the xell(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed' 1 copy of this record has been provided to the well owner.
For multiple iryection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 305 (fL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (1-) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) 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 Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 5 Method of test: Air 24c.For Water Sunaly Iniection Wells: In attrition 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- 100 completion of well construction to lithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013