GW1-2021-00316_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
CRANVAL D LEDFORD 141 ft. 143 ft.
Well Contractor Name f. fL
NCWC4431-A Zft-
SING°(for NC Well Contractor Certification Number DIAMETER THICKNES MATERIAL,CHEROKEE WELL DRILLING 0 6.125 ir' SDR 21 PVC plasticCompany Name ft'IN O- UB G(geothe osed oo ),
2.Well Construction Permit#: W2020000569 2020000486 FROM TO DIAMETER TIRCICNES MATERIAL
List all applicable well construction pertmits he County,State, Variance,eta fL ft. in.
3.Well Use: ft' ft' in.
7: t�YEEN
FROM TO DIAMETER THICKNES4 SLOT SIZ MATERIAL
Residential ft. ft. in
fL ft. is
FROM TO MATERIAL EMPLACEMENT METHOD 8c AMOUNT
fL ft.
ft. ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
M ft.
4. Date Well(s)Completed: 2/8/2021 Well ID# DEER FIELD ft. ft.
5a. Well Location: -
2O�D �L NG-�oGc(fta aY_�ttos�dtnec, saty) --
List all applicable well construction pertmits(ze County,State, Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,gam size,etc)
STEVE GOGGINS 0 fL 7 ft. Red Hard Slate
Facility/owner Name Facility ID(if applicable) 7ft. 39 ft. Gray Hard Granite SET CASING
DEERFIELD DR MURPHY 28906 Lot DEER FIELD 39& 141 ft. Gray Hard Granite
Physical Address,City,and Zip 141 fL 143 ft. Gray Fractured Granite FRACTURE 50 GPM
Cherokee 456100308781000 143% 305 % Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/lotg is sufficient.) 21`REMA S'
35.043101 N -84.134183 W BIT SIZE 5.989"
6. Is(are)the well(s): Permanent
22. Ce cation:
7. Is this a repair to an existing well: No 2/15/2021
If this is a repair,fill out known well construction information and explain the nature of the Si a led9600a�,V,4
Date
repair under#21 remarks section or on the back of this farm. B1 signing this form I hereby certify thate)constructed in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.6200 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 irftction or non-water wells ONLY with the same constructions,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 list all depths if different(example-3@ 200'an d 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 (ft.)
construction to the following:
If water level is above casing,use"+^
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): 50 Method of test: Air 24c.For Water Supply Infection 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 Deoartment of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013