GW1-2022-09076_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD For Internal Use ONLY: E
This form can be used for single or mutiple wells
14.WATER S
1.Well Contractor Information: -
FROM TO DESCRIPTION
WILLIAM LAWSON 1611E 162 fL
Well Contractor Name 533& 534 fL
NCWC3491A s
5.OiITER CA�G for n7h cased w FOR. E (f applica le)
yy eb .w
NC Well Contractor Certification Number , ,; ��5 ^'FROM TO DIAMETER TFUCKNESE MATERIAL
0 ft- 80 fL 6.125 in- SDR21 PVC plastic
CHEROKEE WELL DRILLING StP � � 2022
Company Name fL ft. in.
In;,c. sen ?I A3 Ur;d 6. RCASING O TUBING(geothermal closed oop
2.Well Construction Permit#: W2022000240 20401000.5DG FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits fie County,State,Variance,etc M ft, m-
3.Well Use: & D' In.
1'I:rSCREE
FROM TO DIAMETER TI3ICKNES SLOTS MATERIAL
Residential ft. fL in.
it ft.
18.GRO T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 & 3 ft
ft 20f4
tt. fL
9. D/GRAY A ifap Lcab
FROM w TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. fL
fL fL
4. Date Well(s)Completed: 7/21/2022 Well ID#
fL ft.
5a. Well Location: 20.D ING OG(attac addition s eels ecessary.
List all applicable well construction pertmits#e County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc)
DEAN&LORI KAUFFMAN 0 fL 63 fL Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 63 fL 80 fL Gray Hard'Granite SET CASING
DIAMOND COVE RD MURPHY 28906 Lot 80 tL 161 & Gray Hard Granite
Physical Address,City,and Zip 161 ft. 162 , .fL SMALL'FRACTURE 0.5 GPM
Cherokee 447900642389000 162 ft. 533 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 533 ft. 534 ft. SMALL?FRACTURE 0.5 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
5341E 605 ft. Gray Hard Granite
s
(If well field,one lat/long is sufficient.) 21. MA S a J
35.001426 N -84.090125 W BIT SIZE 5.89"
6. Is(are)the well(s): Permanent
22. ACe7. Is this a repair to an existingwell: No 7/22/2022
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signsertified Well C tractor 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 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of welts 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-)
construction to the following:
IfwaterTeveT is above casing use"+"
Division of Water Qnality,Information Procession Unit,
11. Borehole diameter: 6 (irr) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection Wells: In addtion to sending the form to the address in 24a
12. Well construction method: Rotary air t
(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): 1 Method of test: Air 24c.For Water Supply 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 Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013