GW1-2022-06555_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.E WATER-ZONES
FROM TO _DESCRIPTION
WILLIAM LAWSON 65 ft.. 66. ft.
Well Contractor Name 120 ft. 124 ft
NCWC3491 A 15.6UTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TFIICKNES4 MATERIAL
CHEROKEE WELL DRILLING 0 ft. 30 ft 6.25 in 188 Steel-black
Company Name ft. ft in.
116.INNER CASING OR TUBING(geothermal closed loop)
2.IVeII Construction Permit#: W2021000763 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmitc(e County,State,Variance,eta ft. ft in.
3.Well Use: ft. % in.
17.SCREEN
FROM TO _ DIAMETER THICKNES SLOTS MATERIAL
Residential ft. ft in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
0 fL 20 ft
6 % ft
pp, .2 % ft.
19.SAND/GRAVE_ L PACK(if-applicable) -
�.a +Sl{ 11.1 OM TO MATERIAL EMPLACEMENT METHOD&AMOUN
c^e um I
ft. ft.
ft. ft
4. Date Well(s)Completed: 3/28/2022 Well ID!# PARADISE PARK P/O T ft. ft.
Sa. Well Location: I20.DRILLING LOG(attach additional sheets if necessary)
Lit all applicable well construction perimis fle County,State'Variance;eta FROM TO DESCRIPTION(color,hardness,soil(rock type,grain size,etc)
EDWARD ORAVETZ SEC 1 0 ft 5 ft Red Soft Dirt
Facility/Owner Name Facility ID(if applicable) 5 ft. 30 ft Gray Hard Granite SET CASING
374 PARADISE RD MURPHY 28906 Lot 1 PARADISE PARK 30 ft. 65 ft. Gray-Hard Granite '
Physical Address,City,and Zip 65 ft. 66 ft. SMALL FRACTURE 3 GPM
Cherokee 551103312950000 66 ft. 120 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 120% 124 ft. LARGE FRACTURE 50 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 124% 200. % Gray,Hard Granite
(If well field,one lat/long is sufficient.) 21.-REMARKS
35:05439- N- -83.969954 W BIT SIZE 5.99"
6. Is(are)the well(s): Permanent
22. Certi 914C4.0acl,
7. Is this a repair to an existing well: No 3/30/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature e Date
repair under 4 21 remarks section or on the back of this form. By signing this form,I hereby certify that the weil(s)was(were)constructed in accordance
with 15A NCAC 02C_0100 or 15ANCAC 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 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 if necessary.
9.Total weil depth below land surface: 205 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 20 (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 (iri.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Iniection 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,Undergr•oun Injection Control Program,
• 1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 Method of test: Air 24e-For Water Supply Iniection Wells: In addtion to sending the form to
the addiess(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 Environment and Natural Resources -Division of Water Ouality Revised-Jan 2013.