GW1-2021-05679_Well Construction - GW1_20210727

f Prfiit Form y
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James R.Wilson 14.WATER ZONES
Well Contractor Name FROM TO DESCRUMON
@ ft.
NCWC 2404A
m n
NC Well Contractor Certification Number 15.OUTER CASING for muld-canal wells OR LINER Hesble
Wilson Well Drilling, Inc. FROM To DIAMETER THICIOSBSS MATERIAL
0 ff. 87 ft 825 fn. SRR21 PVC
Company Namc
W2020000668 16.INNER CASING OR TIIBlxG(geothermal elosed4
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Ls.UiC.County.State.Variance,etc.) It. ft. in.
3.Well Use(check well use): ft fL la.
Water Supply Well: 17.SCREEN
FROM TO I DIAKV= I iSLOTSIZE I THICKNESS I MATERIAL
Agricultural []MunicipaUPublic % ft. in.
Geothermal(Heating(Cooling Supply) x®Residential Water Supply(single) ft. ft, in.
Industrial/Cornmercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPiAACBMENT METHOD&AMOUNT
Non-water Supply Well: o ft 20 ft Portland Graft-6begs
Monitoring DRecovery fL it.
Injection Well:
ft ft.
Aquifer Recharge C]Graundwater Remediation
19.Aquifer Storage and Recovery Salinity Barrier FROM
TO MATERIAL
PACK MATERIALif e EMELACEMENT METHOD
Aquifer Test ElStoratwater Drainage
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets If uetxssa
Geothermal ea' Coolin Return Other lain under#21 Remadcs FROM TO DESCRIPTION robe buds wtUrock m cm
0 R 6 ft- Red Clay
4.Date Well(s)Completed:3-08-2021 Well ID#W2020000668 a ft. so It. Send Stone
Sa.Well Location: 60 ft. 120 ft' Granite
Guy Markley tt m
ac ty/Owner Name Facility lD#(if applicable) ft' ft'
l0 %treamside Ln. Murphy, NC 28906 '� 7 2
Physical Address,City,and Zip ft' ft nil
Cherokee 440900854659000 zl•REMARKs n
R5ec...,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: \
(if well field,one tat/long is sufficient) 22.Certification:
x WQ,,�a3-08-2021
--^" 6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified well Contractor Date
By signing this form,i hereby certo that the well(s)was(were)constructed to accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis Is a repair,fill out known well construction iormation 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 thisform.
23.Site diagram or additional well details-.
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I 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: 126 (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdtffawa(example-3Qa 200'and 1 a@1001 construction to the following:
10.Static water level below top of using:60 (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: 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 this form within 30 days of completion of well
12.Well construction method: 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) 15 Method of test:Air 24c.For Water Supply&Infection 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 county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016

July l 6,,2021
`.Information Management
Division of Water Quality
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Well.Construction/Abandonment Records
Dear Information Management:
Enclosed are"well construction/abandonment records for the following aocations:
Location Job# Date
4830 Old Pineville Road; Charlotte, NC 13.661 07/14/2021
7.110 Sandy Forks Road;Raleigh, NC 13658. 06/30/2021 "
3700 Old Battleground Road; Greensboro, NC . 13639 ` 06/29/2021
4794'Lookout Dam Road; Statesville, NC 13662 07/03/2021
Sincerely,
Karen Byer"
SAEDACCO, Inc. :
Enclosure(s)
9088 Northfield Dr. ♦ Fort Mill,SC 29707 ♦.www.saedacco.corn ♦ [phone] ♦ Phone (803)I548-2180 ♦ Fax [phone]
South Atlantic:,Environmental Drilling and Construction Co:

REMRTO Phone:82M7.0963 wiIsonwelldriitingftahoo.com
Wilson Well Drilling,Inc. Fax:[phone] www.wilsonwOlinc.com
ers.ess�o Pal Box 176 F
Brasstown,NC 2890E
I
Bill To: Guy Markley Ph-ata4ta•rm invoice S: 126156
Address: Fez Invoice Date: S/26/2021
Emil;ludymorkloy@gmall com
gE well&pump.Streamstde Ln.Cherokee Co.(drill date:3-08.2021)
use:prMate topograpey:naysofl:ctay,rock:9nmlte,yk10:16gpm,sptla wl.:aa'Awilizoaan:HTH pellets ftv"Wr
Item Description Qty Warranty Exg,Date Price
Drilling $12.00/R 126, $1,512.00
PVC Casing $S.00/rt. 67' $335.00
Pump 1/2hp 10gpm 1 S•years 5/25/2026 $625.00
Pioe In Well 1"160 Roll 1Do. $88.00
Sub Cable 10.2wg 100' $122.00
Torque Anestor 1 $10.s0
Shrink 1 $3.72
Electrical Tape 1/2rell $2.50
Strap damps 4 $16.72
GaN.Bushing 11/4"xl" 1 $5.78
GaN.Bushing 1"4/2' 1 $3.83
Gahr.Tee 1" 1 $5.95
Galt'.Nipple 1"x6" 1 $6.78
Gely.Nipple 1"x3' 2 $6.58
Galy.Nipple 1/4"x3" 1 $3.72
Galy.Nipple 1"z12" 1 $11.97
Coupling 1" 2 $7.78
Galy.Adapters 1" 2 $11.20
Pressure Gauge loopsi 1 $7.56
Galv.Union 1" 1 $12.04
Well Seal 61/4'xl" 1 $36.38
Tank Cross 1" 1 $44.87
Pressure'rank FL7 1 5years S/25/2026 $276.00
Pressure Switch 4G-60 1 $29.30
Rellef Valve 1/2' 1 $11.66
Boiler Drain 1/2"Threaded 1 $10.79
Boiler Drain 1/2"Threadless 1 $9.79
Romex Connectors 1/2" 2 $0.88
Ball Valve 1"PVC 1 $6•00
Ball Valve 1"Brass 1 $23.97
PVC 90 1" 4 $3.60
PVC Tee 1" 1 $1.09
PVC Male Adapter 1" 4 $3.20
PVC Pipe 1"Sch40 10, $7.90
Well Cover small rock 1 $195.95
Fllter Housing 10"BB 1 $109.00
Chad Valve 1'Brass 1 $40.9S
Galv.Street L 1" 2 $9.72
PumpTag 1 $7,04
Well Vent 1/2" 1 $2.29
PVC Cop 1" 1 $0.79
Lawn Hydrant 1 $165.00
LABOR 3 men 3 hrs $300.00
Tax materialsAwIng,labor $180.80
Well Permit Fee $300.00
Involce5ubteM $4x&D
Thank You For Your Business[ 0.00%
$0.00
i
Total due In 30 days,Overdue aowunts aublea to a service Charge or l.5%PerMonth. Total Due $ 4,575.60