GW1-2021-05419_Well Construction - GW1_20211119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James R.Wilson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. fL
2404A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a lieable
Wilson Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 6.25 1D' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-log
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,l7ariance,etc.) ft. ft. in,
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Portland Gravity-5 bags
Monitoring ®Recovery fL ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stomrwater Drainage
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. q ft. Red Clay
4.Date Well(s)Completed: 10-28-2021 Well ID# 4 ft. 60 ft Sand stone
5a.Well Location: 60 ft. 226 ft Granite
Steve Burdette
Facility/Owner Name Facility ID#(if applicable)
940 Prince Rd. Murphy, NC 28906
Physical Address,City,and Zip ft. ft.
Cherokee 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/Iona is sufficient) 22 rtification:
N W 10-28-2021
6.Is(are)the well(s) Permanent or Temporary gnature of Certified Well Contractor Date
By signing this form,1 herebv cerlgi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or 15A NCdC 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction in formation and explain the stature of the copy of this record has been provided to the well owner.
repair tender#21 remarks section or or 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 226 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 26v,'I00') construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the forrit to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Pellets Amount: 30 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016