GW1-2021-02804_Well Construction - GW1_20211022

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
G W 1-2021-02804
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Jimmy Wilson [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner 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#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/28/2021 4
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Joann Smith Facility ID#
(Required) (If applicable)
County* Parcel Identification No. (PIN)
Cherokee
Physical Address* Street Address
Squirrel Haven
Address Line 2
City State/Province/Region
Murphy NC
Postal/Zip Code Country
28906 us
Latitude* 35.0358107000 Longitude*84.0551722000
Decimal degrees Decimal degrees
................... ............
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain 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
406 surface?
For multiple wells list all depths if different 56
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
80 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
4 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 56.00 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-4 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 48.00 Brown Shale
in feet in feet
48.00 406.00 Blue Slate
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* 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*
� wrrr !WbIaW
Signature of Certified Well Contractor
Submittal Date 10/22/2021