GW1-2021-01984_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For hitemal Use ONLY:
This form can be used for single or mutiple wells
14,WATER ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
CRANVAL D LEDFORD 176 ft. 178 ft.
Well Contractor Name ft, ft.
NCWC4431-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER MCKNES MATERIAL
CHEROKEE WELL DRILLING 0 fL 100ft- 6.125 in. SDR 21 PVC plastic
Company Name fL ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2021000263 FROM TO DIAMF IER. THICKNF.S MA'T'F?RIM.
List all applicable well construction perhnits#e County,State,Variance,etc ft. ft. i1L
ft. ft. in.
3.Well Use:
17.SCREEN
FROM TO DIAMETER ~THICKNES SLOTS IL-' MATERIAL
Residential ft. ft. in
ft. ft. in.
I&GROUT FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
0 fL 20 fL Bentonite P
ft ft.
ft. ft. - --
19.SAND/GRAVEL PACK(if applicable)
FROM 1'0 MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 6/2/2021 Well ID# COOPER TR 1
- - M fL
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertinits he County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soitrock type,grain size,etc)
ANDREW SPEER 0 ft. 69 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 69 ft. 100 fL Grey Hard Slate SET CASING
180 MARRESTOP RD MURPHY 28906 Lot 100 ft. 176 ft. Gray Hard Slate
Physical Address,City,and Zip 176 ft. 178 & FRACTURE 10 GPM ID
Cherokee 452000928848000 178 ft. 305 ft. Gray Hard Slate
County Parcel Identification No.(PIN) ft. ft. 5
5b. Latitude and Longitude degreeslminutes/seconds or decimal degrees: it. ft. ,UN " O UI}>11
(If well field,one Iat/long is sufficient.) 21.REMARKS C�9,0ce+s"
35.018144 N -84.245143 W BIT SIZE 5.987" fir+ ,tt'.3D`Vp'SgCU
6. Is(are)the well(s): Permanent ---
22. C tYon /�
7. Is this a repair to an existing well: No 1 //c 6/9/2021
If this is a repair,fill out known well construction information and explain the nature of the S ttue 1 to
repair under#21 remarks section or on the back of this form. gy ngning flex form I hereby certify that the wells)was( re)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stard2rds and that a
8 Number of wens constructed: 1 copy ofthis record has been provided to the well owner.
For multiple i4ection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 305 00
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is aboNe casing use"+^ construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 in. 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For iniection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push etc.) above,also submit a copy ofthis form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division otWater Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 10 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department ofthe county
where constructed.
Form GW-1 North Carolina Deuartme nt of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013