GW1-2021-03625_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.-WATER`ZONES
1.Well Contractor Information: ---:__.---__=-
FROM TO DESCRIPTION
CRANVAL D LEDFORD 110 ft 111 ft
Well Contractor Name ft ft
NCWC4431-A 45.OUTER CASING(for multi-cased well OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 B• 30 R• 6.125 in. SDR 21 PVC plastic
Company Name ft ft in.
16.INNER CASINGOR TUBING(geothermal closed loop).
2.Well Construction Permit#: 202100145 2020000358 FROM TO DIAMETER TMCKNESE MATERIAL
List all applicable well construction pertmits(te County,State,Yartance,etc. fk ft. in,
3.Well Use: B• B• 1O
17.SCREEN
FROM TO DIAMETER TMCKNES SLOTS MATERIAL
Residential It fk in.
ft fk in.
18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 R- 2
ft ft
ft. ft.
19.SAND/GRAVEL PAT CK(if applicable)'
FROM TO MATERIAL EMPLACEMENT METTIOD&AMOUN
ft ft.
4. Date Well(s)Completed: 5/26/2021 Well ID# ft. ft
ft ft
5a. Well Location: 20.DRILLINGLOG(iittech additional sheets if necessary)
List all applicable well construction perimits fle County,State,Variance,etc. '.-----_ (co
JON STECKLEIN FROM TO DESCRIPTION(color,hardness,sod/rock type grain size etc)
0 ft. 6 ft. Soft Topsoil
Facility/Owner Name Facility ID(if applicable) Eft. 30 ft Black Hard Granite SET CASING
1471 BATES CREEK RD MURPHY 28906 Lot 30 ft 110 ft Black Hard Granite .<
Physical Address,city,and zip 110 ft 111 ft FRACTURE 0.5 GPM
'9
Cherokee 459400304090000 111 ft 505 ft Black Hard Granite
County Parcel Identification No.(PIN) ft. ft �
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: B• R• pvv T; AA
(If well field,one tat/long is sufficient.) 21.REMARKS
- -- - -- -
35.128498 N -84.040127 w \��J�C�• ���� "
6. Is(are)the well(s): Permanent
22. C
cn
7. Is this a repair to an existing well: No 5/26/2021
If this is a repair,fill out known well construction information and explain the nature of the SignaDate
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 15ANCAC 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,yvu 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: 20 (ft.) 24a.
24a.For All Wells: Submit this for 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 Iniection 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): 0.5 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 Department of Environment and Natural Resources - Division of Water Ouahty Revised Jan 2013