GW1-2022-07469_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
.WAT R S
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 103 ft 104 ft
Well Contractor Name fL ft
NCWC3491 A 5.O _,ER GA ING for ti-ca e U ER(dapp
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft- 55 ft• 6.125 in SDR 21 PVC plastic
Company Name ft' ft' m'
6. GA G O UB G geo a l c ose o0
2.Well Construction Permit#: W2022000336 2016000009 FROM TO DIAMETER TfUCKNESI MATERIAL
List all applicable well construction pertmits(ze County,State,Variance,eta ft, ft, in,
3.Well Use: ft. ft in.
17.5 > E
FROM TO DIAMETER THICKNES SLOT SI# MATERIAL
Residential ft. ft in
p61VED
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
J L�1 L 0 R- 20 ft
Ura ft ft.
VX 9.S . /GRA G (jf a ca e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft.
ft. ft
4. Date Well(s)Completed: 8/4/2022 Well ID# THE MEADOWS @ FO
ft. ft.
5a. Well Location:
0. ING OG a c adrhtio a sheets' ecessary
List all applicable well construction permits fie County,State, Variance,eta FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
MARCIA FENNEN LOT 1 0% 22 ft Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 22 ft. 55. ft Gray Hard Granite SET.,CASING
175 MEADOW CREEK LN MURPHY 28906 Lot 55 ft. 103 :ft. Gray Hard:Granite
Physical Address,City,and Zip 103 ft. .104 ft. 'SMALL FRACTURE 0.5 GPM
Cherokee 454200529395000 104 fL 605 fL Gray Hard Granite
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.)
35.073547 N -84.196282 W BIT SIZE 5.82"
6. Is(are)the well(s): Permanent
22. Certi_fi n•
7. Is this a repair to an existing well: No ��" 8/5/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contra r 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 1 SA NCAC 02C.0200 Well Construction Standards and that a
& 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: 605 (ft)
For multiple wells list all depths if different(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 (ft)
constrvction to the following:
If water level is above casing,use'+"
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.alr
24b.For Infection Wells: In a i ddtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this forri 30 days of completion of well
construction to the following., i r,
FOR WATER SUPPLY WELLS ONLY: Division of Water Qua*,:Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,.NC,27699-1636
13a. Yield(gpm): 0.5 Method of test: Air 24c.For Water Sup aly.Injection 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: 24 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
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