GW1-2022-09268_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 290 ft 291 it
Well Contractor Name it. ft.
NCWC3491A15, t?; RCAIN�fo ultiwells UR (ifa
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 100 ft 6.125 1- SDR21 PVC plastic
Company Name ft. ft. rrr
16. _ _R - SIN O _ G geothe c o oop
2.Well Construction Permit#: W2022000547 8/20/76 FROM TO DIAMETER nECKNES MATERIAL
List all applicable well construction pertmits fie County,State, Variance,etc % ft, in
3.Well Use: ft. ft m
-7:SCREE_
FROM TO DIAMETER TIUCKNES4 SLOTSJ# MATERIAL
Residential ft. ft. in.
tt. ft. in.
OCT
I (► J r1 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
U 20 0 ft. 3 fL
11*if3r' iC 1 r,d e w:3 uril 3 ft ft
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 9/20/2022 Well ID# SIMPSON'S MOUNTAI
5a. Well Location: r20. RIL�G La(attachridditionals eer
List all applicable well construction pertmits he County State, Variance,etc "
JOSEPHVERGALITO FROM TO TO DESCRIPTION(color,haziness,soiUrock type,grain size,etc)
0 ft. 78 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 78% 100 ft Gray Hard Granite SET CASING
337 SIMPSON MTN RD MURPHY 28906 Lot 16&17 100 fL 290 ft. Gray Hard Granite
Physical Address,City,and Zip 290 ft. 291 ft. SMALL!FRACTURE 1 GPM
Cherokee 443900233308000 291 ft. 300 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 300% 505 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/mjnutes/seconds or decimal degrees: ft. %
(If well field,one lat/long is sufficient.) 1 1V RKS s`.
34.992151 N -84.237141 W BIT SIZE-5.79"
6. Is(are)the well(s): Permanent
22. Certificati
7. Is this a repair to an existing well: No 9/21/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of C ' edOeHiContr�actlor Da
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
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple i4ection 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: 505 (M)
For multiple wells fist all depths ifdtfferent(example-3@ 200'and 2 @ 100') 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
If water level is above casing,use'+" construction to the following:
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 Injection 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 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 Sunnly 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.
Form GW-1 North Carolina Deoartmau of Environment and Natural Resources - Division of Water Ouahty Revised Ian 2013