GW1-2021-02556_Well Construction - GW1_20210811

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 480 ft. 481 ft,
Well Contractor Name 630 ft. 631 ft.
NCWC3491 A 15:OUTER CASING(for'mulbsed webs)OR LIVER(d applrcable) - ='
NC Well Contractor Certification Number FROM TO DIAMETER MCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 fL 70 ft- 6.25 to SDR 21 PVC plastic
Company Name ft. fL in.
116 71VNER CAS_IlYG OR_1'UBING:(geothermal cYo`sed�loop) -_� _
2.Well Construction Permit#: 0358 FROM TO J DIAMETER THICKNESq MATERIAL
List all applicable well construction pertmits Oe County,State, Pariance,etc tti ft, in.
3.Well Use: fL ft. m.
FROM TO ^DIAMETER THICKNES SLOT SIZ MATERIAL
Residential ft. ft. in
IRSFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
G 1 2021 o ft. 3 ft
AV unit3 fL 20 fL
ft. ft.
^3p�'� �rl�On 9 SAPID/GRAVEL AGK rfa hcabLle G, g,� <r =w
�ie�3t1" r�5
FROM TO MATERIAL J EMPLACEMENT METHOD&AMOUN
ft. flL
fL ft.
4. Date Well(s)Completed: 7/16/2021 Well ID# BARTLETT GLEN COVE fL ft.
5a. Well Location: 20 DRILLINGS (atta'�chaddlitional sheets dnecessary)
List all applicable well construction pertmas#e County,State,Variance,etc
FROM TO DESCRIPTION
(color,hardness,soil/rock type,grain size,etc)
PATRICK GROS LOT 35 0 t't. 49 ft. Brown Medium Dirt
Facility/Owner Name Facility ID(if applicable) 49& 70 ft. Gray Hard Granite SET70'CASING
440 HIGH MTN VIEW BRYSON CITY 28713 Lot 35 BARTLETT GLEN COVE 70 ft. 480 R Gray Hard Granite
Physical Address,City,and Zip 480 ft. 481 ft. Fractured SNAL-L FISSURE 0.25 GPM
Swain 667203408335 481 ft. 630 ft. Gray Hard',Granite
County Parcel Identification No.(PIN) 630 ft. 631 ft. Fractured SMALL FISSURE 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 631& 805 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 1 REMARKS'J r s _:3__
35.372503 N -83.447473 W BIT SIZE 5.96"
6. Is(are)the well(s): Permanent
22. Ce cati
7. Is this a repair to an existing well: No 8/11/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of C ed Well ontra r Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of dus record has been provided to the we11 owner.
For multiple itftction 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: 805 (fL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 300 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" construction to the following:
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): 0.75 Method of test: Air 24c.For Water SHRRIV Iniection!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: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Denartmcut of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013