GW1-2022-06558_Well Construction - GW1_20220504

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WAT R ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 295 ft. 296 ft.
Well Contractor Name 400 ft. 402 ft.
NCWC3491A 5.O -ERCrASING for nlh=cased;w O
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 46 ft' 6.125 i"• SDR 21 PVC plastic
Company Name ft ft. in.
6. RCA ING O TUBIN geotherma c ose pop
2.Well Construction Permit#: W2022000170 FROM TO DIAMETER MCKNES4 MATERIAL
List all applicable well construction pertmits(e County,State, Variance,eta % ft. in.
3.Well Use: ft ft in.
7.SCREE
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft. j in.
ft. ft. 1 in.
8GROUT
1®�� � FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
0 ft. 20 ft
MAY 0 4 2022 ft. ft
% ft.
9 �DGlicp_-e
4AR""1{�,� �5 �.ptt��r����9;��t�tt FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
a '±'t,"Cl. r"r OCL- tlt75 ri Lai ft. ft
ft. ft.
4. Date Wells)Completed: 4/29/2022 Well ID#
ft. ft.
5a. Well Location: 20. N (a additiona sheets'f ecessary.
List all applicable well construction pertmits tie County,States Variance etc FROM TO DESCRIPTION(color,hardness,soiLrock type,grain size,etc)
JIM URMSON 0 fL 26 ft. Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 26 ft. 46 ft. Gray Hard Granite SET CASING
853 PLEASANT HILL RD MURPHY 28906 Lot 46 ft. 295 % Gray Hard Granite
Physical Address,City,and Zip 295 ft. 296 % SMALL FRACTURE 2 GPM
Cherokee 440900989222000 296 fL 400 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 400 ft. 402 ft. LARGE'FRACTURE 13 GPM
5b. Latitude and Longitude degrees/ndnutes/seconds or decimal degrees: 402 fL 425 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) MA S
35.002798 N -84.3123466 W BIT SIZE 5.97"
6. Is(are)the well(s): Permanent
22. Cetrttif ad n•
7. Is this a repair to an existing well: No LPL/� G' ✓ o?d�
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
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 15A NCAC 02C.0100 or 15A NCAC 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 well depth below land surface: 425 (ft.)
For multiple wells list all depths if dif ferent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (tit.)
construction to the following:
If water level is above casing use"+" Division of Water Quality,luf6rmatlon 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(glint): 15 Method of test: Air 24c.For Water Supply Iniectionl 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: 18 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 Oualitv Revised Jan 2013