GW1-2021-06294_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON � ,� 290 ft. 291 fL
Well Contractor Name 1�j 515 ft. 516 fL
NCWC3491 A ��Q tQr�0-Og\ SING(f mniti cased wells),ORT�INER(ff,applicable`) Y _
NC Well Contractor Certification Number O�� (E)oj~' FROM TO DIAMETER TTIICKNES MATERIAL
0 ft
CHEROKEE WELL DRILLINGo 60 ft 6.25 "' SDR 21 PVC plastic
t o�
Company Name ��'J ft- ft. in.
16 CASING OTi`TUBING eothermal closedloo a,
2.Well Construction Permit M W2021000435 2021000002 FROM TOy DIAMETER TIECKNES4 MATERIAL
List all applicable well construction pertmits(re Country;State,Variance,etc ft. ft. in
3.Well Use: ft. ft. in.
�� .,.
FROM y TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft. ft. in.
fL ft. in.
�8.G7LOUT ,, ,�-�•-.� c��`;�.'�, 1. -�,.�,a.. .'��;+'��-,p���"`�.' �.,
- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 20 ft
ft. ft
fL fL
=19 SAND/G12Av,F.L,P4$CsB(rf apphcableu _
FROM TO~ Nw MATERIAL EMPLACEMENT METHOD&AMOUN
fL fL
fL ft.
4. Date Well(s)Completed: 9/9/2021 Well ID# HIDDEN HILLS EST
ft. ft.
5a. Well Location: p
�20 DRILLING--LOG�(aftach addrtonal sheets Jtfnecessary�
Lice nll applicable well cansbuctian perfirits fie C.nunt}t SYnti�Variance,etc FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc)
KENNETH LAJOIE P/O SEC 2 0 fL 37 fL Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 37 fL 60 ft. Gray Medium Granite SET CASING
650 HIDDEN HILLS EST MURPHY 289W Lot HIDDEN HILLS EST 60% 290 fL Gray Medium Granite
Physical Address,City,and Zip 290 fL 291 fL Fractured, SMALL FRACTURE 0.5 GPM
Cherokee 454200042641000 291 fL 515 fL Gray Hard Granite
County Parcel Identification No.(PIN) 515 ft. 516 ft_ Fractured SMALL FRACTURE 2.5 GPM
5b. Latitude and Longitude degrees/ndnutes/seconds or decimal degrees: 516 fL 605 fL Gray Hard Granite
(If well field,one lat/long is sufficient)
35.081291 N -84.213673 W BIT SIZE 5.82"-
6. Is(are)the welt(s): Permanent
22. CeAf .4tifiContractor
7. Is this a repair to an existing well: No
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signa Date
repair under#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 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the we owner.
For multiple iryection 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'ic,provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths if different(exmnple-3@ 200'and 2 @ 100') SUAHTTAL INSTRUCTIONS
10.Static water level below top of casing: 100 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If venter level is above casing,use+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 011.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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): 3 Method of test: Air 24c.For Water Supply InieclionlWeBs: 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: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoartmart of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2011