GW1-2022-10463_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1`4 WATER ZONES
1.Well Contractor Information:
FROM TO _ DESCRIPTION
WILLIAM LAWSON 175 ft. 176 ft
Well Contractor Name 547 ft 548 ft
NCWC3491A 15:"OUTER CASING,(for multi-cased_wells)OR 11 LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER T11ICKNESE MATERIAL
CHEROKEE WELL DRILLING 0 ft 40 ft- 6.125 in, SDR-21 PVC plastic
Company Name ft ft in.
16.INNER CASING'OR TUBING(geothermal closed loop) .
2.Well Construction Permit#: FROM TO DIAMETER TIRCKNESl MATERIAL
List all applicable well construction pertmits(te County,State,Variance,etc. ft ft
3.Well Use: ft fk in.
17.SCREEN �~ __ _
a a� FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential < �' " �¢ ��T ; ft ft
N O V 1 a 2022 ft. ft. in
18:'GROUT.
IRiiyi vlil$�lx^7r`Gr: j i,r:� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. ZO fk ?nn Gravity
ft ft
ft ft
19 SAND/GRAVEL PACK(tf applicable)
FROM ft TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft ft
4. Date Well ft ft.
Completed: 11/10/2022 Well ID# BARTLETT GLEN COVE ft fk
5a. Well Location: 10._DRILL_IN_G.LOG,(attach additional sheets if necessary)_
List all applicable well construction perlmits fle County,State,Variance,etc. FROM TO y DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
GREG CODY HEATHER ALLEN LOT 36 0 ft 17 ft Brown Medium Slate
Facility/Owner Name FacilityID(ifapplicable) 17 fk 40 ft Gray Hard Granite SET CASING
450 HIGH MOUNTAIN VIEW BRYSON CITY 28713 Lot 36 BARTLETT GLENN COVE 40 ft 175 ft. Gray Hard Granite
Physical Address,City,and Zip 175 ft 176 ft SMALL FRACTURE 0.5 GPM
Swain 667203404284 176 ft 547 fk Gray Hard Granite
County Parcel Identification No.M 547 ft 548 ' ft. SMALL FRACTURE 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 548 ft. 705 ft Gray Hard Granite
(If well field,one Wong is sufficient.) 2L REMARKS
35.381865 N -83.448114 W BIT SIZE-5.79"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No �7n �� 1/11/2022
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under it 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 15ANCAC 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 injection or non-water wells ONLYwith the same construction,you can 23. Site diagram or additional vrell 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: 100 (ft)
construction to the following_
Ifwater level is above casing,rise"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 276994617
12. Well construction method: Rotary air 24b.For Infection 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 ofwell
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 Infection 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 Ouality Revised Jan 2013