GW1-2021-03059_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Randy Hampton :14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3151 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multZ sed;wells ORLINER if a licable
Southeast Water Productions, Inc. FROM To DIAMETER TxiCIINFSS MATERIAL,
ft. ft. I in.
Company Name
WZOZ 1 OOO 131 -16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TRICKINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) ft. ft. Kn.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
SAND/GRAVEL PACK if a liceble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLA CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. ft.TO DESCRIPTION color,hardam soiVrock e, in size,etc.
4.Date Well(s)Completed: 6-08-202 1 well ID#w2021000131 ft. ft.
Sa.Well Location: ft. ft
Rebecka Allen ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. R
Alpaca Lane, Murphy, NC 28906 tt• ft. informotion Processing Uni,
Physical Address,City,and Zip ft. It. DVVK becliull
Cherokee 440900895752000 21.REMARKS
County Parcel Identification No.(PIN) Hydro Fracture of Well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
N W ha�jo �/4�r 6/15/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signatute of Certif Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: IlYes or ❑No 1 SA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page'to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if eli erent(example-3@200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Pellets Amount: 30
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018