GW1-2021-02685_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD For Internal Use ONLY:
"!Iris form can be used for single or mutiple wells
4. AVER7A.�S ' -
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 250 ft 253 fL
Well Contractor Name 475 fL 476 ft.
NCWC3491 A S QUTER aA ING(for ultased�w. Is O DER(ifapp'sabre)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 1-50'~ f>.125 �� SDR 21- -PVC plastic
Company Name ft' ft' hL
6 INNER GAS �G OR UBING.geoth I.cl p
lllerrr R .r:.�Pe:..tt lf• 1A/7n7AAnn771: lA/7n7nnnA77o _
�._. .._... ri•r-�•r••••.,. - MUM lu iTuvvusi.usE i-tti�nivca - iVlt\•ice N-.
List all applicable well construction pertmits#a County,State, Variance,eta IIL ft. fn
3.Well Use: ft ft in
FROM TO DIAMETER THICKNESSLOTS MATERIAL'— l
Residential �, I� tt ft. in.
�I JIL tit. in.
18.�GROUT :�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
09
ocm3�to,� See°n o .
Its
1511 Gravity
fL
fL fL
let p�,ti fL ft.
�9.S' /GRA .ACc (�f,n lice e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
M ft.
ft. ft
4. Date Well(s)Completed: 7/20/2021 Well IIH# HIDEAWAY HILLS
tL fL
5a. Well Location:
L20R71'�LtING I OG attach a ditlona s teets.rfnecessa �
List all applicable well construction pertmits he County,State,Variance,etc
EMBREE J. PEARSON JR. LOT 65 0 it. 122 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 122 ft. 150 fL Gray Hard'Granite SET CASING
797 PAW PAW TRL MURPHY 28906 Lot 65 HIDEAWAY HILLS 150 fL 250 fL Gray Hard Granite
Physical Address,City,and Zip 250ft 253 ft. Fractured SMALLFISSURE0.5"GPM
Cherokee 455300407979WO 253 ft 475 ft Gray Hard Granite
County Parcel Identification No.(PIN) 475 ft. 476 fL Fractured SMALL FISSURE 2.5 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 476 fL 605 fL Gray Hard Granite21 REMAR R k ��'K �
(If well field,one lat/long is sufficient.) 350—
35.96936 N -84.17131 W BIT SIZE 5.99"
6. Is(are)the well(s): Permanent
22. Curti atio
7. Is this a repair to an existing well: No 8/6/2021
ij•ierixisa.rapair�feii•.uui•known:nr;u.uonsiruciiun;infurmwiun,arul•eRpiainine:nuiure-u�"iiw- .Signature I. onlraoer ie
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 I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
-fi'or multiple iryectlon.or non-water wells ONLY with the same construction,you can
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 01.)
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10.Static water level below top of casing: 80 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above caring use"+"
Division of Water Quality,Information Procession Unit,
11. $orehote dfamefer: $ (ur) 161"TMall ServieeCenter,Rateigli,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): 3 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: 30 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoattment of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013