GW1-2021-02469_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
x
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON ft. ft.
Well Contractor Name fL it
NCWC3491A 5O_UTERICAl51rTG(fortmultr casked�w_7e 1s� IER_�taPPfi e
NC Well Contractor Certification Number FROM TO DIAMETER UUCKNES MATERIAL
CHEROKEE WELL DRILLING U 100 ft 6.125 SOR 21 PVC_plastic
Company Name % ft. in.
6�INNE Ce1�S G O �T 1N (geotltermal;,clos t oop
o pion r,em-.=ctien Pe-a-t+!- !RI1(!7f AA!1??1 !R/9!!91!!!1R/1S7 s.. ,
rxvna TO i�ttuvtxir�ee rnr�,xrv�o mtiinxuu.
List all applicable well construction pertmits(ze County,State, Variance,etc. it. fL in.
3.Well Use: & ft. in.
7 SCREEN 'FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential & & in
ft. ft. in
NNJ 18 GROUT 'r "r
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
, 112oti1 v��� Q za f ft.
nCeg"o(I
0
� `��jtA��Ser'�`•On 19.SV_ /GRAB L�,1C (if appl�c�a--se),
�� Q FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. fG
ft_ ft.
4. Date Well(s)Completed: 8/3/2021 Well ID# WHITE OAK PARK
ft. ft.
5a. Well Location: 20DRi:L OG ahadditi na s Bets if necessary ��r_-
List all applicable well constriction pertmits lie County State.Variance.etc
+.v.. �vv , u,• ,vw•wv • n j�v.y»♦. . 'w)
FRANKLYN WHIDDEN LOT 3 0 ft 70 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 70 ft. 80 ft. Gray Medium Slate
62 PINESVILLE PARK MURPHY 28906 Lot 3 WHITE OAK PARK 80 ft. 100 R Gray Hard Granite SET I W CASING
Physical Address,City,and zip 100 ft. 605 % Gray Hard Granite
Cherokee 551201482385000 & ft.
County Parcel Identification No.(PIN) fL R
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: fL fL
(If well field,one laUlor!g is sufficient)
35.099854 N -83.96918 W BIT SIZE 5.98"
6. Is(are)thewell(s): Permanent
22. Certifi Lion
7. Is this a repair to an existing well: No 8/11/2021
lj ihis is a repair,jiff out known weff construction itr)urmation and expimn the nature ofthe Signature of C. 'W 11 Contractor O-
repair under#21 remarks section or on the back of this form. By signing thts form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple iry'echon or non-water wells ONLY with the same construction,you can 23. Site diagt•aiti or additiuttai tveil detau3:
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: 605 (ft.)
r'or mufiipie wefis fief ail depths Y'aift-retn lexmnpfe-3tw iffy'and 2 aLt t tnrl SUAHTTty—INS-.
24a.For Ali Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 301 (FL)
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 follnwine:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0 Method of test: Air 24c.For Water Supply Infection 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: 10 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 Oualuv Revised Jan 2013