GW1-2021-03967_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 4 WATERZO ,z s
FROM TO DESCRIPTION
WILLIAM LAWSON 73 ft. 75 fL
Well Contractor Name F 165 fL 170 ft.
NCWC3491A �� 15UUTERCING foiinult,caed�we_w R Rtfiappb a A.
._.
NC Well Contractor Certification Number 1, 11 FROM TO DIAMETER IMCKNES MATERIAL
CHEROKEE WELL DRILLING U L un 0 fL 30 ft- 6.125 in- SDR 21 PVC plastic
Company Name 1Dj,,r,,3tton�rt3�SSlfl(,� fL ft in.
p,,rgp,sert10Il I
2.Wen Construction Permit#: 022-1078 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits Oe County,State, Irariance,etc R & in.
3.Well Use: M R- in.
FROM ro VTO DIAMETER THICKNES SLOTS MATERIAL
Residential M ft. in.
fL ft. in.
G OU- im
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 M 20
fit. ft.
fL ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft
4. Date WeH(s)Completed: 7/7/2021 Well ID# LUDLUM SUBD LTS 1,2 R' ft
M fL
5a. Well Location:
0 L Gi a' tacli ad Ottts Bets ifs ce_ �ry ,
List all applicable well construction pertmiGr fie County State I�anance,etc FROM ` Yam' ` I (r�r�
RIM
OWEN GIBBON FROM TO DESCRJPTION(color,hazdness,soiUrocktype,gain size etc)
0 fL 5 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 5 fL 30 ft. Gray Hard Granite SET CASING
LUDLUM DR HAYESVILLE 28904 Lot 30 ft. 73 fL Gray Hard.Granite
Physical Address,City,and Zip 73 fL 75 fL Fractured LARGE FISSURE 20 GPM
Clay 553100359591 75 fL 165 fL Gray Hard Granite
County Parcel Identification No.(PIN) 165 fL 170 fL Fractured LARGE FISSURE 100 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 170 fL 185 fL Gray Hard Granite
s ti �n
(If well field,one latAorg is sufficient)
83.901 N -35.067 W BIT SIZE 6.03"
6. Is(are)the well(s): Permanent
22. Certi cation:
7. Is this a repair to an existing well: No � g!�
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature ertifi e 1 Con actor
repair under 4 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 1 SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the Hey owner.
For multiple irgection or non-water wells ONLY with 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: 185 (fL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 40 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is abovecasing,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
12. Well construction method: Rotary air 24b.For Injection 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:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 100 Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the fort 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 Ouality Revised Jan 2013