GW1-2021-08122_Well Construction - GW1_20211105

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Nov 012021
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James Daniel Wilson. 14.wATERZONES
Well Contractor Name FROM TO I DESCRIPTION
4303A ft R.
ft. ft.
NC Well Contractor Certification Number
1S.OUTER qj R4G for multi-cased welb OR LIl++i1:RR >kable
Wilson Well Drilling,Inc. FROM To DIAMETER 1HICIavEss MATERIAL
Company Name o % I as & 625 in. SOR21 PVC
16,INNER CASING Olt TDBING thermal CIMM"00111
-'--- -2.Well Construction Permit#:_ _ _ _ _ _- .. --. FROM---. -'M _-"-_ DIAMETER I THICIOGM I MATERIAL
Litt all applicable well construction permitr 11-e.UIG Coady,State,Variance,etc-) R ft. is
3.Well Use(check well use): ft ft in
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOT suz THICIORM MATERIAL
Agricultural ® utricipal/Public R. fr. in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) & ft.
IndustriaUCommeroial DResidential Water Supply(shared) is.GROUT
Ini lion FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 0 ft. 20 R Portland GraW"bags
Monitoring 1311ccovery ft. R
Injection Well:
R. ft.
Aqutfer Recharge [3Groundwater Remediation 19.SMM/GRAVEL PACK a ticable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACRNENTMRTROD
Aquifer Test ®Stormwater Drainage % ft.
Experimental Technology QSubsidenee Control R. R
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG fattach additional sheets U necessary)
Geothermal(Hearin Coo' Return) noaier(explain under#21 Remarits FROM TO DESCREMON(color hardnem aoiureck gpe,grain rh%eta
0 ft. 48 ft. Brown Shale
9-28-2021
4 Date Wells)Completed:. Well ID# 48 it. 406 ft- blue slam
Sa.Well Location:. _. IL ft. _
Joann Smith % ft
Factlity/OwnerName Facility@0(ifapplicable) % it AO
as �L
Squirrel Haven,Murphy,NC 28906 M ft.
Physical Address,City,and Zip ft ft W"
CHEROKEE 21.REMARKs u.rt Vd .r,,, '��t;;,,l.l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in deg mWatinutes/seeonds or decimal degrees:
(if we0 field,one lat/long is sufficient) 2 ertif 'on:
N W �`� 9-28-2021
6.b(are)the we .AgPe—Ruent, or Temporary Well Contractor Date
BY stgntng this jmtn I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or dNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out Anown well contraction information and explain the nature of the ropy oftha record has been provided to the well owner.
repair ruder#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 406 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtfftxnt(ermnp/e-3®200'and 2@/003 construction to the following:
10.Static water levci below top of casing:80 (ft) Division of Water Resources,Information Processing Unit,
Ifwvtw level is abate casing use"+^ 1617 Mail Service Center,"efgb NC 27694-1617
- 11.Borehole diameter._6 (in.) 24b For Infection Wells: in addition M sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12 Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Contra!Program,
FOR WATER`SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a:Yield(gpm),4 Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
a=„ the address(es) above, also submit'one copy of this form within 30 days of
13h.Disinfeciiun'typ..e: HTH Pellets Amount 30 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depmtmcnt ofEnvironurental Quality-Division of Water Resources Revised 2 22-2016