GW1-2022-08940_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES ,.
FROM TO DESCRIPTION
WILLIAM LAWSON 120% 121 ft.
Well Contractor Name 662 fL 663 ft.
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NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER 7MC10ES MATERIAL
CHEROKEE WELL DRILLING 0 % 60& 6.125 f in. SDR21 PVC plastic
Company Name ti' ft. I'
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 0448 FROM TO DIAMETER TIECKMSt MATERIAL
List all applicable well construction pertmils(e County,State,Variance,eta % ft. I in.
3.Well Use r l�.W> ^s fL ft. in.
C-s G•"Residential StP i °
FROM TO DIAMETER THICKISH SLOT S MATERIAL
� 2�2� & fL
fL ft. f, in.
IJRI - ..
18:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 it. 3 ft- Bentonote.Rell tts 50 Gravity
fL 20ft
It ft.
19.-SAND/GRAYELPACK(if applicable)--- -`-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft.
% ft.
4. Date Well(s)Completed: 8/17/2022 Well ID# FONATANA TRACE f
M ft.
Sa. Well Location: i20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(!e County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
RON LAROCQUE LOT 23 0 ft. 50 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 50 fL 60 fL Gray Hard Granite SET CASING
840 FONTANA TRACE RD ALMOND 28702 Lot 23 60 fL 120 ft. Gray Hard Granite
Physical Address,City,and Zip 120 fL 121 fL SMALL FRACTURE 0.25 GPM
Swain 663200432883 121 fL 662 % Gray Hard Granite
County Parcel Identification No.(PIN) 662 fL 663 tit. SMALL FRACTURE 0.25 GPM
5b. Latitude and Longitude degrees/rmnutes/seconds or decimal degrees: 663% 705 fL Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS` _
35.377118 N -83.583833 W BIT SIZE-5.97" !
6. Is(are)thewell(s): Permanent
22. Cr WCwd
7. Is this a repair to an existing well: No I 8/18/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signa Well Co actorl" 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 ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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: 705 (ft.)
For multiple wells list all depths if di ferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTION&
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24a.For All Wells: Submit this'form within 30 days of completion of well
10.Static water level below top of casing: 160 (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
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12. Well construction method: Rotary air 24b.For Iniection 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: I,
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FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a. Yield(gpm): 0.5 Method of best: 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. II
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013
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