GW1-2021-02156_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: A
WILLIAM LAWSON "��� FROM TODESCRIPTION
RECEWell Contractor Name 261 ft. 263 ft.
'u i 2021
NCWC3491 A JUL 5.0 ,ER ASING(fo u1flsea
NC Well Contractor Certification Number processing Unit FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING intGirl',�[)WR Secf'On 0 ft. 50 fL 6.25 in- .188 Steel-black
Company Name fL ft. in.
2.Well Construction Permit#: 022-1049 FROM TO DIAMETER TIECKNESI MATERIAL
List all applicable well construction pertmits(ee County,State, Variance,eta fL ft in.
3.Well Use: fL ft in
FROM TO DIAMETER TiIICKNES SLOT Sl# MATERIAL
Residential % ft. in
fL ft. in
.G O .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 % 20
ft_ ft.
ft. ft.
_a : _ . .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft
fL ft.
4. Date Well(s)Completed: 7/2/2021 Well ID#
ft. ft.
5a. Well Location: rr # _
20�D�2Q����INC�� ttac , ona _ ai[�tces a
List all applicable well construction pertmits(e County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soillrock type gain size,etc)
RONALD SALZER 0 ft. 50 ft Brown Clay&Gravel
Facility/Owner Name Facility ID(if applicable) 50 ft. 87 ft Gray Hard Granite
165 MATHESON COVE RD MURPHY 28905 Lot 87 ft• 88 fL Fractured SMALL FISSURE 2 GPM
Physical Address,City,and Zip 88 ft. 261 ft. Gray Hard Granite
Clay 545900437440 261 fL 263 ft. Fractured LARGE FISSURE 100 GPM
County Parcel Identification No.(PIN) 263 fL 285 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. M
(If well field,one lat/long is sufficient.)
35.009308 N -83.828866 W BIT SIZE 5.62"
6. Is(are)the well(s): Permanent
22. Ce�Catio :7. Is this a repair to an existing well: No 7/9/2021
If this is a repair,fill out known well construction information and explain the nature ofthe Signaturtr or Date
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 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 i4ection 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: 285 (fL)
For multiple wells list all depths if& erent(example-3@ 200'and2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of rasing: 60 (ft-)
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 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 thisform 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(glint): 100 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: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Derailment of Environment and Natural Resources - Division of Water Oualitv Revised Ian 2013