GW1-2022-06755_Well Construction - GW1_20220713

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fort can be used for single or mutiple wells
4,yWA1 ER ZONES _ ,z
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 102 ft. 104 ft
Well Contractor Name
fI. ft
NCWC3491 A 15 OUT>R CASINGS(for molt cased��gclls)OIt IJIN);R('applicable)
NC Well Contractor Certification Number FROM TO DIAMETER URCKNESEE MATERIAL
CHEROKEE WELL DRILLING 0 R• 40 R• 6.125 SDR21 PVC plastic
Company Name & ft lin.
16 INNER CASING OR UBINGa'(gcotlte l close-d loop)
2.Well Construction Permit#: W2022000327 FROM TO DIAMETER' TI-ECKNE&I MATERIAL
List all applicable well constnuetiorrpertmits fle Count},State,Variance,eta iL ft I in.
3.Well Use: iL ft )in.
FROM TO DIAMETER T1RC.KNES11 3LOT SIZE MATERIAL
Residential fL M in
ft ft in
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 20 ft Rentonite - 150 Gravity
-
fL ft
M %
]9 SAND/GRP�%EI, .ACKe(ifaPp➢icable) ,
FROM _TO MATERIAL EMPLACEMENT METHOD&AMOUN
11.iL ft.
ft
4. Date Well(s)Completed: 7/6/2022 Well ID# BEAVER RIDGE LOTS
ft. fL
i•
5a. Well Location: r0 sDRILL_ING LOG(attach�ddtionalysheets`°tY e e ary) �'„
List all applicable well construction perimits de County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) -
TINA THOMAS LTS 20/21A 0 fL 5 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 5 ft 17 ft Tan Hard!Slate
RIVERS EDGE LN MURPHY 28906 Lot 17% 40 ft Gray Hard Granite SET CASING
Physical Address,City,and Zip 40 fL 102 fL Gray Hard Granite
Cherokee 551103047195000 102 ft 104- fL LARGE FRACTU E -GPff---
Coumty Parcel Identification No.(PIN) 104ft 165 ft Gray Hard Granite JUL 13 2022
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: R' fL
(If well field,one lat9ong is sufficient.)
35.059951 N -83.978482 W BIT SIZE-5.97" I
6. Is(are)thewell(s): Permanent
22. CeVc-an I -
i
7. Is this a repair to an existing well: No 7/7/2022
If this is a repair,fill out known well construction infonnation and explain the nature ofthe Signature of Certified Well Contractor a e
repair under#21 remarks section or on the back of this form. By signing thus form,I hereby certify that the well(s)was(were)constructed in accordance--- - -
with 1 SA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
9. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple irgection or non-water wells ONLY with the same consimcdog 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: 165 (ft)
For multiple wells list all depths ifdiJferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 30 (ft) '
24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing use'+" construction to the following: i
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m) 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`foim within 30 days of completion of well
construction to the following: i(
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 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: 100 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 Quality Revised Jan 2013