GW1-2022-03401_Well Construction - GW1_20220315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
-77'77
1.Well Contractor Information: 14 WATER 7.ONES-- --- —
FROM TO DESCRIPTION
WILLIAM LAWSON 115% 116 ft
Well Contractor Name 230% 235 M
NCWC3491 A 5.OUTER GASING(formulh eased wells ORZINER(ifappLc ble) k
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES k MATERIAL
CHEROKEE WELL DRILLING 0 fL 87 fL 6.125 in. SDR 21 PVC plastic
Company Name % ft in.
116 INNER CATS_ING O�i.�TUBING(geothermal cl so ed loop)_.� r , ,r.I�_��.
2.Well Construction Permit#: W202100782 2021000781 FROM TO M DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits#e County,State, Variance,etc % ft in.
3.Well Use: & ft. in.
17 SGREEN
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential % M in.
ft ft in.
Y FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
S 1t ft
20
MAR 16 202? ft ft
19�SAND/GRA?Y'ELPACK rf a hca le��'��'�' �� �
-r ye
F ,�1 t ' FROM TO- — MATERIAL -- J EMPLACEMENT METHOD&AMOUN
ft ft
t ;r 1 , r % ft
4. Date Well(s)Completed: 3/11/2022 Well ID# CHARLIE RAPER PROP
Sa. Well Location: 0 DRILLING_I OG attach additionaltsheets d ec ssa
List all applicable well construction pertmits Cze County,State, Variance,etc FROM TO DESCRIPTION(color,hardness,sorllrock type,gram size,etc)
CHARLES ROS 0 fL 60 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 60% 87 ft Gray Hard Granite SET CASING
83 FELIX RD MURPHY 28906 Lot 87% 115 ft Gray Hard Granite
Physical Address,City,and Zip 115% 116 ft. Gray Fractured Granite SMALL FRACTURE 1 GPM
Cherokee 452300255625000 116% 230 ft Gray Hard Granite
County Parcel Identification No.(PIN) 230 ft 235 fL Gray Fractured Granite LARGE FRACTURE 100
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: It % GPM
21:-REMARKS a
(If well field,one laU sufficient.)
lorg is sucient.)
35.106969 N -84.276971 W BIT SIZE 5.98"
6. Is(are)the well(s): Permanent
22. Ce"ca7. Is this a repair to an existing well: NoIfthis is a repair,fill out known well construction information and explain the nature ofthe Signa ell C tractor Dat
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 1 SA 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 it jecdon or non-water wells ONLY with the same construction,you can 23. Site diagram of idditionil 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 (ft.)
For multiple wells fist all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
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 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): 100 Method of test: Air 24c.For Water Supply IniectioD 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 ofthe county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013