GW1-2021-02460_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Randy Hampton 14:WATERZONES
FROM TO DESCRIPTION
We1lContractorName ft. ft.
3151A fL FL
NC Well Contractor Certification Number 13r OUTER CASING'fdtji lh cs"sed'welli`'ORl INER` a`llcrble
Hampton Well Drilling FROM�ft.
DIAMETER THICKNESS MATERIAL
ft. in.
Company Name
w2021000275 &ENINER`CASING�OR TusING. eothe'rmaHlosed400 2 ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. In.
3.Well Use(check well use): ft. IL In•
17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE I THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public fL %
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft, in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft, fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMP[ACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 201 DRILI:ING,I OG:ettsch:additioniil'sheets'if riecessay.
10Geothermal g/ g ) (explain ) FROM TO DESCRIPTION color,hardness,soWrock a size,etc.)
(Heating/Cooling Coolin Return ❑Other under#21 Remarks ft. fL
4.Date Well(s)Completed: 07/12/2021 Well ID# ft. %
5a.Well Location: fL ft
Joseph Polotto f` ft
Facility/Owner Name Facility ID#(if applicable) ft. IL ir 5 2
Outlook Road Murphy 28906 ft. ft. essing nit
Physical Address,City,and Zip ft. ft iflfC,ICr3 10 guAIRS9IOn
Cherokee 451100639404000 ILREMARKS
County Parcel Identification No.(PIN) Hydro Fracture of Well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
35.040291 N -84.288116 W 7/27/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Sig4ature of Ce fied Well Contrac or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 8Yes or ❑No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 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:
8.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: 745 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@I00�
24a. For AllWells: Original form,to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
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 lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1/2 Method of test:Air
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13b.Disinfection type: HTH Amount: 100
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018