GW1-2021-00951_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.W_.ATRZOIES _ a ,s
FROM TO DESCRIPTION
CRANVAL D LEDFORD 273 ft. 274 ft.
Well Contractor Name 432 ft. 433 &
NCWC4431-A 15 OUTER CA$II!TG(for multr lased Re7ls)ORIiINE_R(if 4pj►6cable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 iL 55 ft. 6.13 1R SDR 21 PVC plastic
Company Name ft- fL in.
6.9i-4 R C ASI��G,Oi21 UBING(geotleerittal ctos d;loop)
2.Well Construction Permit#: 022-1025 FROM TO., DLAMETER THICKNESS MATERIAL
List all applicable well construction pertmiis lie County,State,iVananm etc. ft ft in
3.Well Use: ft. ft. in.
FROM TO,-.� DYMETER THICKNESS SLOT SIZE IMATERIAL
Residential ft. & in.
ft. fL in.
18.GROUT lt,: y ;: Y
y� FROM TO. MATERIAL EMPLACEMENT METHOD&AMOUNT
9 fL
ft
AP A 4 2021 fL &
ft. ti:
�Pi�3IIi�3�i011 i�COC£:S51tF(J,
®v��C� FROM TO MATERLAL EMPLACEMEI�TI'METHOD&AMOUNT
ft. ft.
ft. &
4. Date Well(s)Completed: 3/15/2021 Well ID# FIRES CREEK HILLSIDE
R R
5a. Well Location: L
0 DRII,LTNG=I,OG(attach addjtona`l s"beefs if�teoessarv) , ,_�
List all applicable well construction pertmits&Counry,State,Marrance,etc. FROM TO DESCRIPTION('color;hardness,soil/rock type,grain size,etc)
LARKER LEWIS LOT Oft. 32 ft. Brown Slate
Facility/OnmerName Facility ID(if applicable) 32ft 55 it. Gray Hard Granite SET CASING
RIM TRAIL CIR HAYESVILLE 289D4 Lot 5 HILLSIDE @ FIRES CREEK 55 fL 273 & Gray Hard'Granite
Physical Address,City,and Zip 273 ft. 274 ft. Gray Fractured Granite FRACTURE 1 GPM
Clay 554200642485 274fL 432 ft. Gray Hard Granite
Counry Parcel Identification No.(PIN) 432 ft. 433 IL Gray Fractured Granite FRACTURE 7 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 433 ft 505 tit Gray Hard,Grande
(If well field,one lat/long is sufficient.) 1 REIVIARKS ` ``
35.09306 N -83.862274 W BIT SIZE 5.969"
i
6. Is(are)the well(s): Permanent
22. Ce lion:
7. Is this a repair to an existing well: No 3/26/2021
Ifthis is a repair,fill out known well construction information and explain the nature of the Sign of Certified We ntractor Date
repair under#21 remarks section or on the back ofthis forme
BJ'signing Uus forTn,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
& Nmuber of wells constructed: 1 toys•of this record has been provided to the well owner.
For multiple it jection 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 wen depth below land surface: 505 (fL)
For ultiPle wells list all depths ifdi erent(example-3@ 200'and 2 @ 100) SU141TTAL INSTRUCTONS
10.Static water level below top of casing: 60 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above easing,use"+"
Division of Water Quality,Inforrttat*c..„Pive- „..,.. ...,
11. Borehole diameter: 6 (in.) 1617 Mail Service'i Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection 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
constriction to the following: i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 8 Method of test: Air 24c For Water Supply Injection 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 i
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan 2013
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