GW1-2021-01842_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 2,14
FROM TO DESCRIPTION
CRANVAL D LEDFORD 326 ft. 327 ft.
Well Contractor Name ft. ft.
NCWC4431-A sed uabl � -
NC Well Contractor Certification Number FROM TO DIAMETER nUCKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 40 fL 6.125 in. SDR 21 PVC plastic
Company Name fL fL in.
16 I1�T3 ER CASING OR*T<UB i �geot mrinal closed lodp) - _ __
2.Well Construction Permit#: W2021000146 2020000338 FROMy TO Hz DIAMETER TMCKNESI MATERIAL
List all applicable well construction pertmits(te County,State, Variance,etc, ft. ft, in.
3.Well Use: ft. ft. in.
FROM TO DIAMETER THICK SLOT SIZ MATERIAL
Residential ft. ft. in.
fL ft in
NFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft
MA`( X 3 2021 % ft.
Unit M ft.
Ifitt�rtMat;on Pr��essing -
p�NR SP,don FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL fL
& ft
4. Date Well(s)Completed: 4/26/2021 Well ID# FORSYTH PROP
ft It.
5a. Well Location: I20 DRILLING LaG�attachaddi6onalheeLs rfnec a ') {
List all applicable well construction pertmits#e County,State, Variance,etc. TI
FROM TO DESCRIPTION(color,,hardness,s,soil/rock type,gam size,etc)v�
WALTER DOLL 0 ft. 4 ft. Soft Topsoil
Facility/Owner Name Facility ID(if applicable) 4 fL 40 ft. Gray Hard Granite SET CASING
14553 JOE BROWN HWY MURPHY 28906 Lot 40 ft. 326 ft. Gray Hard Granite
Physical Address,City,and Zip 326 ft. 327 ft. Gray Fractured Granite FISSURE 5 GPM
Cherokee 45660042552000 327 ft. 505 fL Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft_
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. fL
If well field,one lat/long is sufficient. 21 REMA12IfS Ti
a . '
35.18913 N -84.13948 W BIT SIZE 5.927" i
6. Is(are)the well(s): Permanent
22. Certi cation:
7. Is this a repair to an existing well: No 4/29/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Wel on �actor �&�Date
repair under 4 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple injection 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: 505 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
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): 5 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: CHLORINE Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Denartmera of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013