GW1-2021-00944_Well Construction - GW1_20210823

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construction Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-00944
Are you submitting a printed form?* r Yes
F No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Jimmy Wilson [e-mail]
Is this a revision to the form you have previously submitted?*
r Yes F No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4303 A JAMES WILSON WILSON WELL DRILLING
2.Well Construction Permit#:
W2021000109
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
7/13/2021 W2021000109 15
(gallons per minute)"

5.Well Location
Facility/Owner Name
Roy Orr Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cherokee 554602771126000
Physical Address* Street Address
Cross Creek Cove
Address Line 2
Section 2, Lot 18
City State/Province/Region
Andrews NC
Postal/ZZp Code Country
28901 USA
Latitude* 35.2117880000 Longitude*83.8660860000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and e)Plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
106 surface?
Formultiplewells listall depths if different 22
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
20 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
15 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
HTH Pellets 30
14.WATER BEARING/FRACTURE ZONES

From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 22.00 6.25 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Portland Gravity-6 bags
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 2.00 Clay
in feet in feet
2.00 16.00 Decomposed Rock
in feet in feet
16.00 106.00 Blue Slate
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
...............................................................................................................................................................
*rJ 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 copy of this record has been provided to
the well owner.

23.Certification*
Signature of Certified Well Contractor
Submittal Date 8/23/2021