GW1-2022-07470_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 122 ft. 123 ft.
Well Contractor Name 208 iL 210 ft.
NCWC3491 A 5.0. R fiASING for ti s wells QR. NE12(if a p'cab e
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 ft 80 ft 6.125 in SDR 21 PVC plastic
Company Name fL ft' in.
6. R SI G O UB G(geotherma c ose o0
2.Well Construction Permit#: W2022000360 2021000621 FROM TO DIAMETER nUCKNESl MATERIAL
List all applicable well construction pertmits he County,State,Variance,etc fL ft 'in.
3.Well Use: ft' ft' in.
FROM TO DIAMETER THICKNES SLOTS171k MATERIAL
Residential & M in.
�. gf _ fL ft in.
`( %i , Ea I 8.GRO T
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- AIDG Z 0 2Q22 0 ft 20ft. Bentonite
fL ft
twcipnation i'ri^C3E3.'"�7ttJ' LIM ft. ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL fL
fL ft
4. Date Well(s)Completed: 8/5/2022 Well ID# O P LANCE PROP
ft. ft.
5a. Well Location: 0, L IN a c d 'tiona s ee ec
List all applicable well construction pertmits fle County,State, Variance,etc FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
JAMES MCGRATH LOT 25 0 ft. 52 ft Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 52 fL 80 ft. Gray Hard Granite SET CASING
10 COVE LN MURPHY 28906 Lot 25 80 fL 122 fL Gray Hard Granite
Physical Address,City,and Zip 122 fL 123 ft. SMALL FRACTURE 4 GPM
Cherokee 446900676668000 123 fL 208 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 208 fL 210 ft. LARGE FRACTURE 11 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 210 fL 245 fL Gray Hard Granite
(If well field,one lat/long is sufficient.) 1-
35.008959 N -84.122798 W BIT SIZE 5.97"
I.
6. Is(are)the well(s): Permanent
22. Ce ratio
7. Is this a repair to an existing well: No �i�
If this is a repair,fr!l out known well construction information and explain the nature ofthe Signature f ertified Well Contr for 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 15ANCAC 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 well depth below land surface: 245 (ft)
For multiple wells list all depths if different(krample-3@ 200'and 2 Q 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 (tt)
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 Infection 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(gpm): 15 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: 10 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
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