GW1-2022-08941_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 293& 294 ft.
Well Contractor Name 572 tL 573 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 TIIICKNESJ MATERIAL
CHEROKEE WELL DRILLING 0 & 40 ft- 6.125 j in. SDR21 PVC plastic
Company Name fL ft to
16.INNER CASING OR TUBING.(geothermal-closed loop)
2.Well Construction Permit#: FROM TO DIAMETER TIECKNES MATERIAL
List all applicable well construction pertmits(le County,State,Variance,eta fL ft. in
3.Well Use: ft. ft in.
.SCREEN--
FROM TO�� �� ��" DIAMETER THICKNES SLOTS MATERIAL
Residential F, ~�' � '� fL ft � in
Sr P 1 .9 2022 % ft.
18.GROUT
In a.,_ -a<•r�1?ri?Ct?tiwt`,'i19 Unft FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 fL 3 ft
fL ftPumpedfrmn
ft. fL
19.SAND/GRAVEL PACK(if.applicable)- ----__.-----___---_---
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
& 1L
fL ft
4. Date Well(s)Completed: 8/22/2022 Well ID# FONTANA TRACE
fL M
5a. Well Location: 120.DRILLING LOG(attach additional sheets Nnecessary)
List all applicable well construction pertmits(e County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
SCOTT MASTEJ LOT 22 0 fL 10 ft Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 10 fL 40 ft Gray Hard Granite SET CASING
540 FONTANA TRACE RD ALMOND 28702 Lot 22 40 fL 293 fL Gray Hard Granite
Physical Address,City,and Zip 293 ft 294 fL SMALL FRACTURE 1.75 GPM
Swain 663200447105 294 fL 572 fL Gray Hard Granite
County Parcel Identification No.(PIN) 572% 573 fL SMALL FRACTURE 0.25 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 573% 705 % Gray Hard Granite
(If well field,one lattlong is sufficient.) 21.REMARKS
35.378012 N -83.581946 W BIT SIZE 5.95"
6. Is(are)the well(s): Permanent
22. Cert�e '
All
7. Is this a repair to an existing well: No �L 8/23/2022
If this is a repair,fill out known well construction information and explain the nature of the Signatureontra or' Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
S. 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 different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
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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: 100 (ft) construction to the following:
Ifwater level is above casing use'+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (1-) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method Rotary air 24b.For Iniection Wells: In addtion to sending the form to the address in 24a
(ie.auger,rotary,cable,direct push,etc.) above,also submit a copy of this font 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): 2 Method of test: Air 24c.For Water Su I 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: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoarhnent of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013