GW1-2021-01844_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: 4 Z TER
FROM TO DESCRIPTION
CRANVAL D LEDFORD 81% 82 ft.
Well Contractor Name
138 tl. 139 ft.
NCWC4431-A 15.OLTTERGASTI�TG(formulti�sedwell's�ORt.IIVR(if�applrchbg7
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 fL 55 fL 6.125 in. SDR-21 PVC plastic
Company Name ft. ft. in.
16 IIVIVER4CA�ING OI2`TUBING geo ;eTnral ci.osea loop)�� _ � rm
2.Well Construction Permit#: W2021000069 2021000068 FROM TO DIAMETER THICKNES x MATERIAL
List all applicable well construction pertmits f County,State, Variance,etc fL IL in,
3.Well Use: fL FL in.
FROM TO DIAMETER THICKK S SLOT SIZ MATERIAL
Residential y M ft. in.
MAC x 3
2021 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
cSl��U1S1'( 0 tl, 20 ft.
PrOCe�. ft. fl.
1it'S JC1�3�t��sE�1`CP ft fl.
Q 9 )t /BRAWM fr
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fl. fit.
fL ft.
4. Date Well(s)Completed: 4/28/2021 Well EN
tl. 1l.
5a. Well Location: 20 ARILLING I2O�G�atfachsid 'honal s4reets tend cessay)=r =:
List all applicable well construction pertmits(ie County,State, Variance,etc.
FROM TO ^ DESCRIPTION(color,hardness,soil/rock type gram size etc)
EDDIE&CHARLOTTE NORTON 0% 42 ft. Red Hard Slate
Facility/Owner Name Facility ID(if applicable) 42 ft. 55 ft. Gray Hard Granite SET CASING
10270 JOE BROWN HWY MURPHY 28906 Lot 55 fL 81 fL Gray Hard Granite
Physical Address,City,and Zip 81 % 82 % FRACTURE 10 GPM
Cherokee 456400674613000 82 ft. 138 it Gray Hard Granite
County Parcel Identification No.(PIN) 138 fL 139 % FRACTURE 10 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 139 fL 205 % Gray Hard Grande
(If well field,one lat/long is sufficient.)
35.14677 N -84.13389 W BIT SIZE 5.914"
6. Is(are)the weil(s): Permanent
22. 7 lion:
7. Is this a repair to an existing well: No 4/29/2021
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signadied We Contractor ate
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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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: 205 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 (tl.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater level is above casing,use'+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (1-) 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
(Le.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): 20 Method of test: Air 24c.For Water Supply Infection Wells: hi addtion to sending the forth 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