GW1-2021-00317_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
94, `AT g o r-..
1.Well Contractor Information:
FROM TO DESCRIPTION
CRANVAL D LEDFORD 322 fL 323 tit.
Well Contractor Name 581 R 582 lit.
NCWC4431-A SOTR CCASING for ti d s Q R p' b e
NC Well Contractor Certification Number FROM TO DIAMETER TIIICKNESEE MATERIAL
CHEROKEE WELL DRILLING 0 fL 90 R- 6.125 hL SDR 21 PVC plastic
Company Name ft. R' in.
6. R_ G O G eo erm coed
2.Well Construction Permit M W2020000514 2020000517 FROM TO DIAMETER TfHCKNES4 MATERIAL
List all applicable well construction pertmits(e County,State, Variance,etc ft, ft, in.
3.Well Use: ft. D' m
FROM TO DIAMETER THICKNES SLOT Sl# MATERIAL
Residential fL fL in.
ft. fL in.
8 G120UT _�'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
it. ft,
�;• .
t 021 0 0
AA rr\\ 2 ,t. ft.
ft. 1L
Mill,S. D/G 4 LAC ,(ifs p'ca e
J
•�. ri; ^ --Cr, Otl FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL M
R. ft.
4. Date Well(s)Completed: 3/4/2021 Well ID# WELL# i M fL
5a. Well Location: 2U.DRIB LOG(attac ad onais ,necessa .
List all applicable well construction pertmits#e County,State,Variance,etc FROM« TO DESCRIPTION(color,hardness,soil/rock type,gam size,etc)
RHUBARB LLC THE REFUGE 0 fL 61 ft. Brown Slate
Facility/Owner Name Facility ID(if applicable) 61 tL 90 ft. Gray Hard Granite SET CASING
REFUGE RIDGE RD MURPHY 28906 Lot 90 ft. 322 R. Gray Hard Granite
Physical Address,City,and Zip 322 ft. 323 ft. Gray Fractured Granite FISSURE 1.5 GPM
Cherokee 452200999550000 323& 581 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 581 & 582 ft. Gray Fractured Granite FISSURE 6.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 582 ft. 625 fL Gray Hard Granite
(If well field,one lat/long is sufficient.) Em
35.09133 N -84.25123 W BIT SIZE 5.914"
6. Is(are)the well(s): Permanent49
22. Certification:
7. Is this a repair to an existing well: No 3/5/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 1 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 iry'ection 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: 625 00
For multiple wells fist all depths if&fferem(example-3@ 200'and 2 @ 1001) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 100 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
water level is above casing,use If "+" 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 Infection 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): 8 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 of the county
where constructed.
Form GW-1 North Carolina Denartrnent of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013