GW1-2022-01195_Well Construction - GW1_20220121

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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. ft.
2404A
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 MATERLAL
p ft. 47 ft. 1 6.25 in. SDR21 PVC
Company Name
W2021000130 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,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 nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
Industrial/Commercial x®Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. Portland Gravity-4 bags
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge n Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test n Stormwater 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,sofl/mck type, rain size,etc.)
p ft. 3 ft. Red Clay
4.Date Well(s)Completed:7-07-2021 Well ID#W2021000130 3 ft. 40 ft. Shale
5a.Well Location: 40 ft' 306 ft' Granite
Sandra Bracewell
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Dickey Rd, Murphy, NC 28906 ft. ft.
Physical Address,City,and Zip ft. ft.
Cherokee 445900498020000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W / 07-07-2021
6.IS(are)the well(s) X Permanent or Temporary S' tore of Certified Well Contractor Date
y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or XINo with 1 SA NCAC 02C.0100 or 15A NCAC 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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-I 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: 306 (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@200'and 2@100') Construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) 3 Method of test: Air 24c.For Water Supply&Iniection Wells: In 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