GW1-2022-01174_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
James Daniel Wilson 14.WATER ZONES
Well Contractor Name FROM ft. ft.TO DESCRIPTION
4303A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CAVING for mti-cased wells ORHLINENR fa icable
Wilson Well Drilling, Inc. FROM T DIAMER TICKE MATERIAL
p ft- 40 ft. 6.25 in' SDR21 PVC
Company Name
W2020000376 16.INNER CASING OR TUBING eother al closed-ES
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.
17.
Water Supply Well: FROMENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Portland Gravity.4 bags
Monitoring DRecovery
Injection Well:
:)Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain s m,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remazks)
p ft. g ft. Red Clay
4.Date Well(s)Completed: 11-22-2021 Well ID#W2020000376 3 ft. 14 ft. Sand Stone
5a.Well Location: 14 it. 506 fl. Granite
Ancel&Kathleen Offutt
Facility/Owner Name Facility ID#(if applicable)
Cherokee Cove, Lot 4, Murphy, NC 28906 ft. ft.
Physical Address,City,and Zip
Cherokee 458400427380000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
N W 11-22-2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
ly signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy 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:
8.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 I 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: 506 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1/8 to 1/4 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm)
the address(es) above, also submit one copy of this form within 30 days o
13b.Disinfection type: HTH Pellets Amount: 30 completion of well construction to the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016