GW1-2021-03626_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Randy Hampton 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3151 A ft. ft.
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING(for multicasedwens ORLINER iIa licable
Hampton Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
W2021000331 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.I TIC,County,State.Variance,etc.) ft. IL
3.Well Use(check well use): ft. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu nicipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL':PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO fL DESCRIPTION color,hardness,soiurock ty1w,grain size,eta
4.Date Well(s)Completed: 08-16-2021 Well ID# ft. ft. c�
ft. fL r9
5a.Well Location:
Franklin Whidden ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
62 Pinesville Park Murphy NC 28906 ft. It
Physical Address,City,and Zip ft. fL
Cherokee 551201482385000 21.REMARKs
County Parcel Identification No.(PIN) Hydro Fracture of Well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35.099854 N -83.969180 W 8/20/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signdurc ofCcroffed Well Contract Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ❑No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fb) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,161 TMSC,Raleigh,NC 27699-1617
If water level is above casing,use'L+"
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 to 8 Method of test: Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Chlorine Amount: 100 PPM
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018