GW1-2022-09267_Well Construction - GW1_20221003

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14. TER )NES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 87 fL 90 ft.
Well Contractor Name 157 fL 160 M
NCWC3491A SOUT<ERC_A5ING fo�rmltacased ells OR R(ifa p e
NC Well Contractor Certification Number FROM TO DIAMETER TMCI NES MATERIAL
CHEROKEE WELL DRILLING 0 fL 62fl- 6.125 in. SDR21 PVC plastic
Company Name ft. ft in.
6. - R GA G O UB G(ge�therma closed oop)
2.Well Construction Permit#: W2022000359 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(re County,State,Variance,etc ft. ft. in
3.Well Use: ft. ft. ir
FROM TO DIAMETER TIHCKNES SLOTSI# MATERIAL
Residential fL fL in.
ft ft. in.
8^GROTJT'•
- - i FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 fL 20 R
ft. ft.
_
0 C 2 0 2 Z % ft.
Uni D RA, ACKt(iftapplica e
FROM LTO L MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft
4. Date Well(s)Completed: 9/27/2022 Well ID# HOLLY POINT @ NOTT
ft. tit.
5a. Well Location: 20. rING OG(atlac d ' oval eels if• ecessa .
List all applicable well construction pertmits(re County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
QINGYAN WANG LOT 40 0% 49 fL Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 49 ft. 62 ft. Gray Hard Granite SET CASING
HOLLY POINT DR MURPHY 28906 Lot 40 HOLLY POINT @ NOTTLEY RIVER 62 ft. 87 ft. Gray Hard Granite
Physical Address,City,and Zip 87 ft. 90 ft. Fractured WATER ZONE 5 GPM
Cherokee 446900295301000 90 ft. 157 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 157& 160 & Fractured WATER ZONE 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 160 fL 205 fL Gray Hart)Granite
If well field,one tat/longis sufficient 21.,REMARKS
35.014255 N -84.139252 W BIT SIZE-5.72"
6. Is(are)the well(s): Permanent
22. Ce li�4&e.
7. Is this a repair to an existing well: No 9/28/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature ontr c or e
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 1 SA 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: 205 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 (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 (irr.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection 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 Service4Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 10 Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the form to
the address(es)above,also submitl one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction tol the county health department of the county
where constructed. fF
Form GW-1 North Carolina Department of Errvironment and Natural Resources - Division of Water Oualitv Revised Jan 2013