GW1-2021-03624_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14i WATER ZONES77
1.Well Contractor Information: `
FROM TO DESCRIPTION
WILLIAM LAWSON 103 ft. 105 ft.
Well Contractor Name tt ft
NCW C3491 A 15.OUTER CASING(formulti-cased wells)OR 3INER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESl MATERIAL
CHEROKEE WELL DRILLING 0 ft. 93 fk 6.25 in. .188 Steel-black
Company Name ft ft. in.
16.INNER CASING ORTUBING(geotheimal closed.loop)
2.Well Construction Permit#: W2021000235 YES FROM TO DIAMETER TIIICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. tt, in.
3.Well Use: ft _ ft in.
17.SCREEN �� :fir
FROM TO DIAMETER THICIQ9ES SLOTS MATERIAL
Residential ft ft. in.
ft ft. in.
Y> �� 18.GROUT
r . Q
V\1� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 20 ft
t7�C' �4\ ft ft
P 19 SAND/GRAVELPACK(ifapplicable) a
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft ft
fk fk
4. Date Weil(s)Completed: 6/14/2021 Well lD# DOLLAR GENERAL
ft ft
Sa. Well Location: 201 DRILLING LOG(attach additionaT`s6eets:if necessary)'r .a
List all applicable well construction pertmits(ie County,State,Variance,etc. -- -- = __._-
THE BROADWAll GROUP,LLC FROM TO DESCRIPTION(color,hardness,sod/rock type,gram size etc)
Oft. 20 ft Brown Dirt
Facility/Owner Name Facility ID(if applicable) 20 ft 75 ft Brown Clay&Stones
12546 W US 64 MURPHY 28906 Lot 75 ft 85 ft Gravel 'CREEK GRAVEL
Physical Address,City,and Zip 85 ft 93 ft Gray Hard Granite SET CASING.
Cherokee 454001179172000 93 ft 103 ft Gray Hard Granite
county Parcel Identification No.(PIN) 103 ft 105 ft Fractured LARGE FISSURE 100 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 105 ft. 145 ft Gray Hard Granite
(Resell field one lat/long is sufficient.) 21.REMARKS'':
35.0382 N -84.20616 W BIT SIZE 5.972"
6. Is(are)the well(s): Permanent
22. Certificatio
7. Is this a repair to an existing well: No 7/29/2021
If this is a repair,fill out known well construction information and explain the nature of the Signs o e Contras at
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certtfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection 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: 145 (ft)
For multiple wells list all depths if different(example-3Q 200'and 2 Q 1009 SUMIITAL INSTRUCTIONS
10.Static water level below top of casing: 60 (ft) 24a.For Ali Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing,use"+" 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:
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 Sunni* Injection Wells:' In addtion to sending the form to
the addresses)above,also submit one copy of this form within 30 days of
13b.`Disinfection type: HTH Amount: 9 completion of well'construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources -Division of Water Ouahty Revised Jan 2013