GW1-2022-01603_Well Construction - GW1_20220201

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4�W,AT�ER�7AIVES u�;�z�-, -
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 180& 181 ft.
Well Contractor Name 220 fL 222 fL
NCWC3491 A 15 OUTERC_ASING(for�mnlhca e'�d w�ells)O_iIIyER�(ifF p lile `
NC Well Contractor Certification Number FROM TO DIAMETER TIIICKNESEE MATERIAL
CHEROKEE WELL DRILLING 0 fL 100 ft- 6.125 in SDR 21 PVC plastic
Company Name ft. ft in.
6 INI�,ER�CfiSING 0�2 TUBING'= eothermalc ose oo
2.Well Construction Permit#: W2021000622 10/10/91 FROM^ TO DIAMETER TIUCKNES4 MATERIAL
List all applicable well construction pertmits fle County,State, variance,eta ft. ft_ in.
3.Well Use: ft. ft. im
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft in.
ft. ft, in.
..-
n _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 3 fL Bentonit
FEB D r , 3 ft. 20 fL Bentonit
1 zoz_ ft. ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 11/22/2021 Well EN PAUL OWENBY PROP
ft. ft.
5a. Well Location:
20 eDRILZ`I�P G Lch`�adi�fiona"?sheens'�ii-n�essa y ��s3�- ,_
List all applicable well construction pertmits he County,State,variance,eta FROM TO DESCRIPTION(color,hardness,sod/rock type,grant size,etc)
MIKE HELSPER LOT 11-B 0 ft. 68 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 68& 100 ft. Gray Hard Granite SET CASING
739 GRAPE THICKET RD MURPHY 28906 Lot 100 ft. 180 ft. Gray Hard Granite
Physical Address,City,and Zip 180 ft. 181 ft. Gray Fractured Granite SMALL FRACTURE 3 GPM
Cherokee 448902852352000 181 ft. 220 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 220 ft. 222 ft. Gray Fractured Granite LARGE FRACTURE 60 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 222% 245 ft. Gray Hard Granite
21 REMARKS
(If well field,one laUlortg is sufficient.) _�--
35.005098 N -84.05094 W BIT SIZE 5.91"
6. Is(are)the well(s): Permanent
22. Certifica�Con
7. Is this a repair to an existing well: No 12/9/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Signature
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 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells construe": 1 copy of this record has been provided to the well owner.
For multiple infection 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: 245 00
For multiple wells list all depths if&fferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (ft.)
construction to the following:
If water level is above casing use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 C—) 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): 60 Method of test: Air 24c.For Water Supply Injection 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: 12 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envirownent and Natural Resources - Division of Water Oualitv Revised Jan 2013