GW1-2021-00940_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 4 WATERZONES ,; _ ur
FROM TO DESCRIPTION
CRANVAL D LEDFORD 287 ft. 288 ft.
Well Contractor Name 557 ft. 558 it.
NCWC4431-A15 OUTERCASING(fo multicase8weils�RIINER'Cfappli aMle)� :`:
NC Well Contractor Certification Number FROM TO oDIAMETER TMCKNES MATERIAL
CHEROKEE WELL DRILLING 0 fL 130 ft. 6.125 in. SDR 21 PVC plastic
Company Name ft. ft in.
d16 R CAS GOR_ UBING(g othermalclosed loop) u � x
2.Well Construction Permit#: W2021000085 2008000339 FROM To DIAIAETER THICKNES w MATERIAL
List all applicable well construction perbnits fie County,State, Variance,eta ft, M in,
3.Well Use: ft. ft. in.
L17SCREEN }r s
FROM TO DIAMETER LTHICKNES SLOT SID MATERIAL
Residential ft. ft. in.
% ft. in.
FROM ... TO �y MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 0 ft
ft. ft.
M ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 3/24/2021 Well ID# OVERLOOK MARTINS
It. ft.
5a. Well Location: 20DRILItIATG�Z €attach adtlon s 1 -
���i'necessary)�, `
List all applicable well construction pertmits Oe County.State, Variance.etc ' �gr x
FROM � T TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc)
JOHN BLACK LOT 10 0 ft. 106 ft. Brown Slate
Facility/Owner Name Facility ID(if applicable) 106 ft. 130 ft Gray Hard Granite SET CASING
75 PARKER PL MURPHY 28906 Lot 10 OVERLOOK AT MARTINS CREEK 130 ft. 287 ft. Gray Hard Granite
Physical Address,City,and Zip 287 fL 288 ft. Gray Fractured Granite FISSURE 0.5 GPM
Cherokee 449901291728000 288 ft. 557 ft. Gray Hard;Granite
County Parcel Identification No.(PIN) 557 It. 558 & Gray Fractured Granite FISSURE 3.5 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
558 ft. 625 It. Gray Hard Granite
If well field,one lat/long is sufficient 211RE S s w "3 n'
35.018044 N -84.038976 W BIT SIZE 5.916"
6. Is(are)the well(s): Permanent
22. Cc lion:
7. Is this a repair to an existing well: No 3/26/2021
If this is a repair,fill out known well construction information and explain the nature of the Signa Ce ed aaontlnct IODate
00
repair under#21 remarks section or on the back of this form. By signing thus form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection 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: 625 A)
For multiple wells fist all depths if&fferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60
ytD (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
� e 9
If water level is above casing use"+" vd r>�S� construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air
��R `§ L 24b.For Infection Wells: In addtion to sending the form to the address in 24a
L}�lt i
(i.e.auger,rotary,cable,direct push etc.) �BESiI@� above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: C'�``''' Division of Water Quality,Undergroan Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a. Yield(glint): 4 Method of test: Air 24c.For Water Sunnly Injection Wells: In addtion to sending the forth 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 the county health department of the county
where constructed.
Form GW-1 North Carolina Deuattment of Environment and Natural Resources - Division of Water Oualtty Revised Jan 2013