GW1-2021-05583_Well Construction - GW1_20211119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James Daniel Wilson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fL ft.
4303A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if
a licable
Wilson Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 25 ft' 6.25 m. SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.GIC,Couniv State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ® nicipal/Public ft. ft. in.
Geothermal(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-4 bags
Monitoring Recovery
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 E3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain sim,etc.)
0 ft. 18 ft. Sand Stone
4.Date Well(s)Completed:8-09-2021 Well ID# 18 ft• 506 tt• Granite
5a.Well Location:
Tommy Shaffer
Facility/Owner Name Facility ID#(ifapplicable)
40 Serenity Lane, 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:
(ifwell field,one lat/long is sufficient) 22. ertifiCa' ri
4
N W 8-09-2021
6.Is(are)the well(s)�ermanent or Temporary S' nature o Certified Well Contractor Date
By signing this fom,I hereby certify that the K-ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or do with 15A NCIC 02C.0100 at-15A NC4C 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy o/'this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
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: 506 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3�aa,1200'and 20,100') construction to the following:
10.Static water level below top of casing:60 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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) 1/2 Method of test: Air 24c.For Water Supply&Injection Wells: hi addition to sending the form 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016