GW1-2021-01487_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
CRANVAL D LEDFORD 329 ft. 330 ft.
Well Contractor Name 400 ft. 401 ft.
NCWC4431-A 15.OUTER CASING(for multi!cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft- 112 ft- 6.125 in- SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2020000411 2020000168 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc. ft ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
vM FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
nite ravity
ft. ft.
p�pGeaS�g ft. ft.
aO��sB�\0 19.SAND/GRAVEL PACK(if applicable),01Q�\
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 4/15/2021 Well ID# HUNTERS CLIFF LOT 4
ft. ft.
Sa. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
KATHY WYMAN 0 ft. 61 ft. Brown Hard Slate
Facility/Owner Name Facility ID(if applicable) 61 ft. 112 ft. Gray Hard Granite SET CASING
310 SKYLAND TRL MURPHY 28906 Lot 4 HUNTERS CLIFF 112 ft. 329 ft. Gray Hard Granite
Physical Address,City,and Zip 329 ft. 330 ft. FRACTURE 10 GPM
Cherokee 455300204054000 330 ft. 400 ft. Gray Hard Granite
County Parcel Identification No.(PRE 400 ft. 401 ft. FRACTURE 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 401 ft. 445 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.09493 N -84.17628 W BIT SIZE 5.979
6. Is(are)the well(s): Permanent
22. Ce ' ication:
7. Is this a repair to an existing well: No '4
/f this is a repair,fill out known well construction information and explain the nature of the Si Certified Well Contractor ate
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.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 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: 445 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 (ft.) 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 (in.) 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 fom r 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): 15 Method of test: Air 24c.For Water Supply lniection'Wells: In addtion 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 the 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