GW1-2022-04467_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Randy Hampton 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3151Aft. ft
NC Well Contractor Certification Number 15:OUTER CASING for moltltased'wells ORkLINER"if a` licAble
Southeast Water Productions, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name
W t�O y 0 W 16.INNER CASING OR TUBING eotliermil closed400
2.Well Construction Permit#. FROM TO I 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): fa ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubtic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft g, in.11
❑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. M
❑Monitoring ❑Recovery ft. M
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.,SAN1i/GRAVEL PACK:if-a 'lics6le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control it ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additionil sheets if necessary)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM ft. To ft DESCRIPTION color,hardo soil/rock type,grain size etc.
4.Date Well(s)Completed: Well ID# ft. ft
5a.Well Location: ft ft .
Patrick Gates ft F-
Facility/Owner Name Facility 1D#(if applicable) ft ft. MAY 0
2
0 7
89 Hibberts Mountain Road,. Murphy ft ft
Physical Address,City,and Zip ft ft
Cherokee 21.REMARKS.'v WOBt11
County Parcel Identification No.(PIN) riyaro rracture oT Water even
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification-
6.Is(are)the well(s): CIPermanent or ❑Temporary Signature o�Well Contral5tor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: InYes or ❑No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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.SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: 605 (R) 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)
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" j
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to!DWR,Underground Injection Control(IUC)
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 department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 O+ Method of test: Air Lift
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
A
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018