GW1-2021-01845_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.WATER
FROM TO DESCRIPTION
CRANVAL D LEDFORD 147 ft 148 ft
Well Contractor Name R ft
NCWC4431-A -
i5,OUTER Ctfi,�lAT��>['or�rttnitr caked=�w�ls�flRF3R(if�apIica��tc�,
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 fL 127 ft- 6 `ur' SDR 21 PVC plastic
Company Name % ft in
6;.��LVCR�CA�ING �T$ t{G,�geotheimalo,q 7oo�p����x<.�, _-
2.Well Construction Permit#: W2020000510 W2020000471 FROM TO DIAMETER STFUCKNESI MATERIAL '
List all applicable well construction pertmits(ie County,State, Variance,etc. M 1L in.
3.Well Use: % D- im
gg-
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Residential % ft HL
fL & in
j4jf;SQT is r, .y ., z " r 'MAM
-minu
° FROM TO MATERIAL~ EMPLACEMENT METHOD&AMOUNT
0 & 20 ft
31p1� & ft
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUN
% ft.
4. Date Weil(s)Completed: 4/28/2021 Well ID# ft ft.
ft. ft.
5a. Well Location:
List all applicable well construction pertmits(ie County.State, Variance,etc
ERIC PACE FROM TO DESCRIPTION(color,hardness,soil/rock type,gam size,etc)
0 fL 32 ft. Brown Hard Slate
Facility/Owner Name Facility ID(if applicable) 32% 83 fL Tan&Gray Hard Slate
60 GLENN NOAH LN MARBLE 289M Lot 83 8, 127 ft. Gray Hard!Slate SET CASING
Physical Address,City,and Zip 127 ft. 147 % Gray Hard Slate
Cherokee 552300392991000 147 M 148 % FRACTURE 15 GPM
County Parcel Identification No.(PIN) 148 fL 205 R Gray Hard Slate
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: % il
IREys 'IN� 1 r 4' k
(If well field,one laUlorg is sufficient.) t =� ,��� ,,�;�.a „€___�s�i � �___,�� r� _:,�r
35.13244 N -83.94113 W BIT SIZE 5.973"
6. Is(are)the well(s): Permanent
22. Ce cation:
i
7. Is this a repair to an existing well: No 4/29/2021
If this is a repair,full out known well construction information and explain the nature ofthe Sigrta of Certifie We ontr ctor 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 it jection 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: 205 010
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 (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 (m.) 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 for in 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): 15 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submit one jcopy 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 Dewriment of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013