GW1-2022-08985_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.1.WeII Contractor Information: WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 225 ft. 226 M
Well Contractor Name 284 ft 285 ft
NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 % 60 ft 6.125 i" SDR 21 PVC plastic
Company Name % ft in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000067 FROM TO DIAMETER TIUCKNESJ MATERIAL
List all applicable well construction pertmits(le Count};State,Variance,eta % ft in.
3.Well Use: M ft. in.
17,SCREEN_
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential & ft in.
ft ft. in.
18.GROUT
FROM TO MATERIAL EMPLACF1v Pr METHOD&AMOUNT
w �A 0 fL 3 ft
Bentonite Pell 50# Gravity
Ar .,a 5 tfa k-- J tt 20ft
SEP ! r 2022 fL fL
19.SAND/GRAVEL'PACK(if applicable)
U111 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
Dli'VOGOG tit. ft
4. Date Well(s)Completed: 6/1/2022 Well ID# W S DICKEY PLACE ft ft
fl ft.
5a. WeIl Location: 120.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits fle County,State,Variance,eta FROM, TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
SHANNON HELTON LOT 14 0 fL 39 ft' Tan Medium Slate
Facility/Owner Name . Facility ID(if applicable) 39 tI 60 ft Gray Hard'Granite SET CASING
165 JACK POT DR MARBLE 28905 Lot
60 flt. 225 tt. _Gray Hard Granite
Physical Address,City,and.Zip 225 tl 226 8 SMALL FRACTURE 2 GPM
Cherokee 551403410567000 226it: 284, ,fL Gray Hard,Granite
County Parcel Identification No.(PIN) 284% 285 fL SMALUFRACTURE 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 285% 305• it. Gray Hard Granite -
(If well field,one lat/long is sufficient.) 21.REMARKS
35.136222 N -83.972378 W BIT SIZE 6.0"
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6. Is(are)the well(s): Permanent
22. Certifica'on: j
7. Is this a repair to an existing well: No '� 7/4/2022
If this is a repair,fill out known well construction information and explain the nature oftlre Signature of Well Contractor Date
repair under 4 21 remarks section or on the back of this form. By signing this form,I hereby cerb;fy that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or45ANCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple irgecdon 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: 305 (ft)
For multiple wells list all depths ifdlfferent(example-3@ 200'and 2 @ 1009 SUNUTTAL INSTRUCTIONS
10.Static water level below top of casing: 10 (ft)
24a.For All Wells: Submit this form within 30 days of completion of well
'
construction 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
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12. Well construction method: Rotary air 24b.For Injection Wells: In,addfron 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,Uitdergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC.27699-1636
13a. Yield(gpm): 4 Method of test: Air 24c.For Water Sunoly 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: 15 completion of well construction to the county health department of the county
where constructed. I �
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013
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