GW1-2022-10842_Well Construction - GW1_20221209

1
WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or mutiple wells
WATER 7(1, S
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON
Well Contractor Name 115 ft. 117 it f
170 ft. 173 ft.
NCWC3491 A SOU ERCAINGfor m tias�dwe OR INER(ifapp'ca e
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 60 fL 6.125 in- SDR21 PVC plastic
Company Name ft- ft. in.
6. NER C+ASI .G OR TUB G eothetma cos loop
2.Well Construction Permit#: W2022000436 2022000297 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ze County,State, Variance,eta it. ft. in.
3.Well Use: ft. ft. im
7.SCREEN
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft, ft_ in
ft. ft. in.
18�GROUT
FROM .a TO MATERIAL EMPLACEMENT METHOD&AMOUNT
f .t ,. G 0 ft. 60
OEC 9 2022 &
9 A DEG ELyA� CK�( 3>�pplicab e y
FROM TO y MATERIAL EMPLACEMENT METHOD&AMOUN
it.
4. Date Well(s)Completed: 11/14/2022 Well ID# TR 547 TARHEEL NOR it. ft.ft. ft.
5a. Well Location: 20. L G OG a c ad 'bona s eats' ec
List all applicable well construction perlmits tie County,State,Vario we,etc FROM TO DESCRIPTION(color,hardness,'soil/rock Type,grain size,'etc)
WILLIAM VALL 0 it. 25 fL. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable)
25 ft., 60 ft. Gray.Hard Granite
t05 LAKESHORE DR MURPHY 28906 Lot 60 M 115 fL Gray Hard;Granite
Physical Address,City,and Zip 115 ft. 117 'fL SMALL FRACTURE 10 GPM
Cherokee . 459209063870000 117 ft. 170 ft: Gray Hard:Granite
`County Parcel Identification No.(PIN) 170 ft. 173 ` & "` LARGE FRACTURE 40 GPM . -
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 173 ft. 205 & Gray Hard Granite
(If well field,one lat/long is sufficient) 7;RF� =835.092207 N -84.048575 W E AP MMWMMWMMWM"
PROVAL NO.JMB2747
-6.02"
6. Is(are)the well(s): Permanent
22. Certificationkolntlr4actor /44WD�at
7. Is this a repair to an existing well: No 11/16/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified
repair under#21 remarks section or on the back of this form. By signing this forms I hereby cerh,f,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
8. Number of wells constructed: 1 copy of thus record has been provided to the well owner.
For multiple iry'ectlon 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 di erent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (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:
Divisiori of Water'Quality,Information Procession Unit,
l 1. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells:' In addiiori 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,Undeigroun Injection Control Program,.
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 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- 100 completion of well construction toe county health department of the county
where constructed.
Form GW-1 North Carolina Deoartrne t of Environment and Natural Resources - Division of Water Oualitv Revised Ian 2013