GW1-2021-05708_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
James R.Wilson
14,WATER=ZON1Well Contractor Name FROM N'NCWC 2404A &NC Well Conector Certification Number
15.OUTER lls OR LINERWilson Well Drilling, Inc. FROM THICKNESS MATERIAL
Company Name 0 73 R• 6.25I SDR21 PVC
022-1044 16.INNER CASING OR TUBING eathermai aimed-ina
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(I.e.UIC,County,State,Vzzriance,etc.) ft. fL !n
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE T_ffTrW PSS MATE RIAL
:)Agricultural �MutticipaVPublic ft. % in.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single)
ft. fL in.
InduStrral/Commercial DResidentiaI Water Supply(shared)
18.GROUT ,
[Aquifer
on FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
ter Supply Well: 0 ft. 20 R Portland Gravity-6 bags
ring Recovery it ft
— Well r Recharge Groundwater Remediation19.SAND/GRAVELPACK a licabler Storage and Recovery Salinity BarrierFAOM TO MATERW EMPLACEMENTMETHOD
r Test 13Stormwater Drainage % fL
ental Technology Subsidence Control it ftrmal(Closed Loop) Tracer 20.DRE LLING LOG attach additional sheets U necessarmal satin Coolie Return Other(explain under#21 Remarks FROM To DESCRIPTION(color,hardo asturoelc etc
0 R• 3 ft- Red Gay
4.Date Well(s)Completed:5-31-2021 Well 1D#022-1044 3 it' 64 ft.
Sand Stone
5a.Well Location: sa ft. 106 ft. Granite
Greg Teems ft. ft.
Facility/Owner Name Facility ID#(if applicable) fit. ft
471 Dog Branch Rd. Brasstown, NC 28902 M ft
Physical Address,City,and Zip ft. fL
CLAY 552000062349 21:REMARKB
County Parcel Identification No.(PIN) OGessing Unit
5b.Latitude and longitude in d UVVR SecP On
gi egress/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 . ertification:
N R' CL, ✓�--- 5-31-2021
6.Is(are)the well(s)OE Permanent or OTemporary gnature 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: Dyes or EJNo 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:
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
9.Total well depth below land surface: 106 (ft.) 24a. For All Wells: Submit this Iform within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2®100� cons to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I
(in.) 24b.For Infection Wells: in addition 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
construction to the following:
(i.e.auger,rotary,cable,direct push,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) 40 Method of test: Air 24c.For Water Suouly&Iniectio� Wells: In addition to sending the form to
HTH Pellets 3o the address(es) above, also submitlone 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. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016
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