GW1-2021-01843_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4�V TER 7ANES '_ , '
1.Well Contractor Information:
FROM TO DESCRIPTION
CRANVAL D LEDFORD 603 ft. 604 ft.
Well Contractor Name ft. ft.
15NCWC4431-A ,0UERCG<omtcaws RC.fa hcalile '
pp )
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 M 40 ft- 6.125 in. SDR 21 PVC plastic
Company Name % ft m
1 6 IPINER GAS)N�'OR'T1JB _G(geo�lteSnwl elos�el�oop)='� _'� �` ,
2.Well Construction Permit#: W2021000222 6/8/05 FROM TOA DIAMETER TTUCKNES MATERIAL ,
List all applicable well construction pertmits(te County,State, Variance,etc. fL ft. In.
3.Well Use: ft• ft. in.
I7 SC72EE .
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential fL ft. in.
u,
A.i=j•'�
FROM TO L MATERIAL EMPLACEMENT METHOD&AMOUNT
N�aY. X 3 2021 0 ft. 20 ft
Un1t ft. ft.
r. 3�i0t3�CCC85SICi� ft. ft.
FROM R. TOy ft. MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 4/20/2021 Well ID# COUNTRY ENCHANTM ft. fL
5a. Well Location: : -
I) DRI)sIsIl�Ci`LOG(atfach ad �honal eefs if>necessa�y) e r - �.�:;
List all applicable well construction perimits(ie Coun)4 State, Variance,etc.
,^, FROM TO DESCRIPPIION(color,hardness,soil/rock type,grain size,etc)
CHARLES EDGAR D ,�.;;�-�I �l� � �e-LL- 0 ft. 12 ft. Brown Hard Slate
Facility/Owner Name Facility ID(if applicable) 12 ft. 39 ft. Gray Hard Granite SET CASING
6 DEREK LN MURPHY 289N Lot 47 39 ft. 322 fL Gray Hard Granite
Physical Address,City,and Zip 322 ft. 349 fL Hard Granite&Quartz
Cherokee 455200497602000 349 ft. 603 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 603 fL 604 ft. FRACTURE 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 604 fL 705 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) S;` _ _
35.09485 N -84.16834 W BIT SIZE 5.974"
6. Is(are)the well(s): Permanent
22. Cc =6cation:
7. Is this a repair to an existing well: No 4/29/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of Cc
net ell Contractor Date
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 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 irjection 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: 705 00
For multiple wells fist all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 320 (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 Iniection 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 Quatity,'Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 1.5 Method of test: Air 24c.For Water Sunply Infection 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: CHLORINE Amount: 100 completion of well construction to the county health department of the county
where constructed.
Fotm GW-1 North Carolina Deoamnent of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013