GW1-2022-10292_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
(14 WATER ZONES
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON 395% 396 ft.
Well Contractor Name 660 fL 662 ft.
NCWC3491 A 15._OUTER CASING(for multt`.cased`yells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESI MATERIAL
CHEROKEE WELL DRILLING 0 ft 50 ft- 6.125 im SDR 21 PVC plastic
Company Name ft ft. in.
116.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: FROM TO DIAMETER MCKNESE MATERIAL.
List all applicable well construction perhnitr(ze County,State,Variance,eta ft. ft. in
3.Well Use: ft ft. 1°
7.SCREEN . _
FROM a TO DIAMETER TMCKNES SLOT SIZI MATERIAL
Residential � ft. ft. in.
� EC E NE D (18:.GR UT ft in
.
NOVy A 20�� FROM TO MATERIAL EMPLACEMENT METHOD RAMOUNI'V V j 0 M 20 ft
ft. ft.
Intorfl�ti«:::1 PrD c4aoir,g Unit
G41/Q/30G f ft.
�19.-SAND/GRAVEL-PACK(if,apphctrble)� - -_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
fL ft.
fL ft.
4. Date Well(s)Completed: 11/3/2022 Well ID#
5a. Well Location: I20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits Cie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
CHRIS ARNOLD 0 fL 32 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 32It. 50 ft. Gray Hard Granite SET CASING
8100 HWY 28 ALMOND 28702 Lot 50 ft_ 395 ft: - Gray Hard,Granite
Physical Address,City,and Zip 395% 396 ft. Fractured_ WATER ZONE 2 GPM
Graham 6623000013901 P 396% 660 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 660 IL 662 ft. Fractured WATER ZONE 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 662% 705 fL Gray Hard Granite
21
(If well field,one lat/long is sufficient.) EMARKS � -
83.59 N -35.393 W BIT SIZE 5.83"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No �h2- 4� 11/3/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Ceram ell Contractor Date
repair under#21 remarks section or on the back ofthis form. signing this form;I hereby certify that the welts was were constructed in accordance
� s g r y r>' rl �_�_�
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
S. Number of wells 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: 705 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 200 (ft.)
If water Ievel is above casing,use'+° construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m) 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 Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 4 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: 25 completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan 2013