GW1-2022-06756_Well Construction - GW1_20220713 (3)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fort can be used for single or mutiple wells
14.WA
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 323 fL 325 fL
Well Contractor NamefL ft
NOWC3491 A 15 OUTER'CASING(fbrxmnitt casedA ellsj OR LINER(if¢applir.►ule)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 75 fL 6.1.25 in SDR21 PVC plastic
Company Name it. M hL
16,INNER CASING OR'�TUBING;(geothennl7closed,
2.Well Construction Permit#: 022-1196 FROM TO DIAMETER URCKNFS4 MATERIAL
List all applicable well construction pertmits(ie County,Stata Varidnce,eta % ft. in
3.Well Use: ft ft m
17.SCREEN �'�
FROM TO DIAMETER '111ICKISMSE SLOTSIZE, MATERIAL
Residential % ft. In.
fL ft hL
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 3 ft
ft 0 ft
fL %
]9 SAND/GRA,UEL PACK(if.ap'IicaUle)= .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft. i
ft. ft. i
4. Date Well(s)Completed: 5/30/2022 Well ID# MCCLURE RD }
ft f1L
Sa. Well Location: 420:pRILLING'I OG(tittach additional sheets if necessary) - ice
List all applicable well construction pertmits ge County,State YarIance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ROBERT FLIPPO TRACT 3 0 ft. 36 ft. Tan Medium'Slate
Facility/Owner Name Facility ID(if applicable) 38fL 75 ft. Gray Hard Granite SET CASING
a30 MCCLURE RD HAYESVILLE Lot 75 fL 323 fL Gray Hard Granite
Physical Address,City,and Zip 323 ft. 325 ft. LARGE FRACTURE 75 GPM
Clay 545802976561 325 fL 345 ft. Gray Hard
County Parcel Identification No.(PIN) it. fL
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: & & J U L 1 3 (�
(If well field,one lat/long is sufficient.) t21 RTMARKS ;, "�
34.993963 N -83.811 W BIT SIZE-5:82" ,�
[� 1,5CTW
6. Is(are)thewell(s): Permanent �A� . .nT , t1T
22. Certification-
7. Is this a repair to an existing well: No L91)% I 7/6/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature o Certified Well Contra r! Date
repair under#21 remarks section or on the back of this form. si run tins orm I hereby certify that the x�ll s was were constructed in accordance
By s g. .'I v fv O (were)
with 1 SA NCAC 02C.0100 or 15A AV iC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1. copy of this record has been provided to the xell 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: 345 (M)
For multiple wells list all depths ifdifferent(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.)
If water level is above casing use'+" construction to the following:
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 I Undergroun Injection Control Program,
1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a. Yield(gpm): 75 Method of test: Air 24c.For Water Supply Injection Wells: In addition to sending the form to
the address(es)above,also submitrone 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 Deoartment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013