GW1-2021-02805_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: �y C NED
��[ -G FROM TO DESCRIPTION
CRANVAL D LEDFORD vvv 161 R. 162 ft.
Well Contractor Name OR 9 202 214& 216 ft.
NCWC4431-A Unit 5 U Rt,C�AS fo tj webs ,O PP ca e
NC Well Contractor Certification Number 1ntorrnglon Process'n9 FROM TO DAAMETER nUCKNES MATERIAL
CHEROKEE WELL DRILLING DWR Seaton 0 it. 65 ft. 6.125 in SDR 21 PVC plastic
Company Name ft ft. m-
6- , R CAI
2.Well Construction Permit##: 0221048 FROM TO DLAivIETER THICKNES MATERIAL
List all applicable well construction pertmits#e County,State, Variance,etc % ft. in.
3.Well Use: ft fL m-
7. p E1�T
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential IIL ft. in
it. ft- in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 20 ft
fL ft.
ft ft.
/G (if p'ca e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft-
fL ft.
4. Date Well(s)Completed: 2/24/2021 Well ID##
ft. fl.
5a. Well Location: --- L a (a a di opals ee ecessa t�
List all applicable well construction perimits(re County,State,Variance.etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JACK LEE ALLEN 0& 23 & Brown Slate
Facility/Owner Name Facility ID(if applicable) 23% 65 & Gray Hard Granite SET CASING
497 THUMPING CREEK RD HAYESMLLE 28904 Lot 65 fL 161 & Gray Hard Granite
Physical Address,City,and Zip 161 & 162 % Gray Fractured Granite FISSURE 3 GPM
Clay 641900273781 162 fL 214 % Gray Hard Granite
County Parcel Identification No.(PIN) 214 ft. 216 fL Gray Fractured Granite FISSURE 15 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 216& 305 ft. Gray Hard Granite
(If well field,one lat4ong is sufficient.)
35.027 N -83.636 W
6. Is(are)the well(s): Permanent
22. cation:
7. Is this a repair to an existing well: No x4Z� 3/1/2021
If this is a repair,Ertl out known well construction information and explain the nature of the S e o ell Contract Date
repair under#21 remarks section or on the back of this form By signing this form,I hereby cer*that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple byechon 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 (ft.)
For multiple wells fist all depths iJ 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 above 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 Injection 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 of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 18 Method of test: Air 24c.For Water Supply Injection 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 of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013