GW1-2022-06278_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14:'WATER-ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 103% 104 ft.
Well Contractor Name 215% 216 ft.
NCWC3491 A 15:OUTER CASING(for multi=cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNESl MATERIAL
CHEROKEE WELL DRILLING 0 ft. 60 fl- 6.125 in. SDR21 PVC plastic
Company Name ft. ft in.
16.'INNER CASING OR TUBING eothermal closed loop)_
(g P). .
2.Well Construction Permit#: 051122-P 053021-S FROM TO DIAMETER TMCKNES MATERIAL
List all applicable well construction pertmits(ze County,State,Variance,eta ft. ft in.
3.Well Use: ft. ft in.
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Recovery ft. ft irr
ft ft in.
low-GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft
% ft
M ft.
19.SAND/GRAVEL.-PACK(ifappHcnble)- - - -; '-�
FROM `TO MATERIAL EMPLACEMENT METHOD&AMOUN
M ft
fL ft
4. Date Well(s)Completed: 6/17/2022 Well M# NANTAHALA HARBOR fit. ft.
5a. Well Location: 120.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits fe County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,gram size,etc)
PATRICKRUSSELL 0 fL 42 'fit. Tan Mediuril'Slate
Facility/Owner Name Facility ID(if applicable) 42 fL 60 ft Gray Hard Granite SET CASING
3574 LITTLE CHOGA RD TOPTON 28781 Lot 60 ft. 103. ft. Gray Hard Granite
Physical Address,City,and Zip 103fL 104 ft. SMALL FRACTURE4GPM
Macon 6505365037 104% 215 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 215% 216 ft. SMALL FRACTU.Ei1E,2,GPM�,.,,a
}}��
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 216 ft 305 fL Gray Hard Granitek'`>
(If well field,one tat/long is sufficient.) ll:V REMARKS'
35.187916 N -83.675819 W BITE SIZE 5.97 JllN�2-g-2022
6. Is(are)the well(s): Permanentrt
22. Cc �c,
WW1'Cn1
7. Is this a repair to an eaistingwell: No 6/20/2022
If this is a repair,fill out known well construction information and aTlydn the nature ofthe Signature for e
repair under 4 21 remarks section or on the back of this form. By mgmng this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 mPell Construction Standards and that a
S. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection 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 ifnecessary.
9.Total well depth below land surface: 305 (ft.)
For multiple wells Iist all depths ifdiferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft) construction to the following:
Ifwater level is above casing,use'+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (1-) 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
(Le.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): 6 Method of test: Air 24c.For Water Supply 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: 12 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Fnwonment and Natural Resources - Division of Water Ouality Revised Jan 2013