GW1-2022-10841_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14 WATER ZONES y_ �� _ }F 1�1 1,I
FROM TO ADESCRIPfION
WILLIAM LAWSON 351 fL 352 ft
Well Contractor Name 455 ft 457 ft
NCWC3491A 18.6 CASING(for multi cased wells)OR LIN_ER�if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 fL 27 fL 6.125 in- SDR 21. PVC plastic
Company Name it ft in-
16.INNER CASING OR'ING(geotbeTmal closed loop),
2.Well Construction Permit##: 022-1220 FROM TO DIAMETER TMCKNES4 MATERIAL
List all applicable well construction pertmits(se County,State,Variance,etc. ft ft in.
3.Well Use: fk ft in.
17 SCREEN4
FROM TO DIAMETER TMCKNES SLOT S MATERIAL
Residential ft fL in.
ft ft in.
(7�"' �'°i t° FROM TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
E �� 'tt. t.�' 0 ft 3 ft
D F C 0 V 2022 3 ft 0L
ft ft
i f42•v 9�I jr'r'7t 19 SAND/GRAVEL]PACK(if s�pplicable);`_ rw
In�., -naOd3 _. TO MATERIAL_.. —. ---
FROM _ EMPLACEMENT METHOD&AMOUN
ft ft
4. Date Well(s)Completed: 11/29/2022 Well IDI# BRASSTOWN TRAILS ft fL
fL ft
Sa. Well Location: 20 DRILLING LOG'(attach additional sheets tf accessary)
List all applicable well construction pertmits fle County,State,Variance,etc. - —•- --_... _ S,._�a_ .._....�_ .d__.., t
MARK RICKETTS FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
LOT 63 0 ft 7 fL Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 7 fL 27 ft. Gray Hard Granite SET CASING
220 WILDFLOWER RDG 11VARNE 28909 Lot 27 fL 351 fL Gray Hard Granite
Physical Address,City,and zip 351 ft 352 ft Fractured WATER ZONE 0.5 GPM
Clay 542900423340 352 fL 455 ft Gray Hard Granite
county Parcel Identification No.(PIN) 455 fL 457 ft Fractured WATER ZONE 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 457 fL 645 fL I Gray Hard Granite
(If well field,one lat/long is sufficient.)
35.002145 N -83.929565 W BIT SIZE 5.5"
6. Is(are)the well(s): Permanent
22. Certi do -
7. Is this a repair to an existing well: No
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Con actor 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 15A NCAC 02C.0100 or 15A NCAC 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 ONLYwith 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: 645 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITl'AL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft.)
construction to the following:
Ijwater level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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 of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail ServiceiCenter,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 addresses)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount 30 completion of well construction to the county health department of the county
where constructed.
Fonm GW-I North Carolina Denartment of Environment and Natural Resources - Division of Water Ouahty Revised Jan 2013
,I