GW1-2021-03149_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
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1.Well Contractor Information: `
FROM TO DESCRIPTION
WILLIAM LAWSON 570 ft. 571 ft.
Well Contractor Name
4
NCWC3491 A 5�"OiJTER GA_SING(for cased w s O R tfapp'cable
y
NC Well Contractor Certification Number FROM TO DIAMETER TFUCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 ft. 70 fL 6.13 "t SDR 21 PVC plastic
Company Name ft ft In.
6.�N1"VERC AS G°QR UBING;(geotherma closedsloo ems"'"
2.Well Construction Permit#: W2021000327 2021000296 FROM TO DIAMETER CCKNES MATERIAL
List all applicable well construction pertmits f County,State, Variance,etc. ft. ft in
3.Well Use: ft. ft in
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential a,� fL ft im
d ft. ft. hL
e ^� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 fL 20
1� t �1;011 tl ft
11Ct1•�10� y��E
/GRAVEL .ACK( pp',ca,_le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
ft. ft
4. Date Well(s)Completed: 6/21/2021 Well ID# SUMMIT @ DICKY M
ft. ft.
5a. Well Location: 2 DRII LINGdL (attach`addfaona s eets'if�necessary)
List all applicable well construction perimits fie County,State,Variance,etc
THOMAS STADTHAGEN FROM TO DESCRIPTION(color,hardness,soil/rock type gram size etc)
0 ft. 57 ft Brown Slate
Facility/Owner Name Facility ID(if applicable) 57ft. 70 ft Gray Hard.Granite SET CASING
572 MOUNTAIN TOP DR MURPHY 28906 Lot 2-8 SUMMIT @ DICKY MTN ESTATES 70 ft. 350 fi. Gray Hard Granite
Physical Address,City,and Zip 350 ft_ 351 ft. Gray Fractured Granite SMALL FISSURE
Cherokee 455004834308000 351 & 570 ft. Gray Hard,Granite
County Parcel Identification No.(PIN) 570 ft. 571 ft. Gray Fractured Granite SMALL FISSURE 1 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 571& 625 ft. Gray Hard Granite
21 REMARKS . t. r '��
(If well field,one lat/long is sufficient.)
35.022358 N -84.152381 W
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No Qy`J 6/22/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certifie W 1 Contractor Date
repair under#21 remarks section or on the back of this form. By signing this farm,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 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 ilection or non-water wells ONLY mLh the same construction,you 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: 625 (fL)
For multiple wells fist all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 220 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
r
12. Well construction method: Rotary air 24b.For Infection 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): 1 Method of test: Air 24c.For Water Supply Infection 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. II
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013
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