GW1-2022-00261_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.'lYATER1Z0NES _.�: ...,�...� ..� .--=,---.�.-,,-•
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAMLAWSON 157 ft. 160 IL I �
Well Contractor Name FL ft
NCWC3491 A 15.OUTER CASV;G(for multi=cased wells)QR I^i 1VER.(iR,appticatile c
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS I MATERIAL
CHEROKEE WELL DRILLING 0 ft 130 fL 6.125 j'm SDR21 PVC plastic
Company Name ft' ft' in'
16:IPTi`>R CaSI: OR T[773I_NG(gcothe_rmal closed Ioop)
2. ;'ell Construction Permit M. W2022000555 FROM TO DIAMETER THICICIESS MATERIAL
List all applicable well construction pertnrits(ie County.State,Lrariance,etc. fL fL
3.1Vell Use: ft fL in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential IL ft• in.
ft fL in.
FROM TO MATERIAL EMPLACEMENT METHOD 3:ANIOUNT
ft. 20 ft. Rentonote Pell I NO Gravity
fk ft.
ft. ft.
19.SA1VD/GRAVEL PCI1(rf apphcable) €
FROM TO MATERIAL EMPLACEMENT METHOD 3 AMOUNT
4. Date Well(s)Completed: 12/16/2022 Well IDl# RIVERWALK/HIWASSE
ft. JIL
5% Well Location: v..
20:3)RILLTi\GLOG(attacli addtionalsheets ifrtecessarc)v-�- - - -
List all applicable well construction pertnnis(te County,State,Irariance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ERIK&PAIGE BRINKE LOT 63 0% 117 % Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 117 ft. 130 fL Gray Hard Granite SET CASING
156 ABRAM WAY MURPHY 28906 Lot 63 RIVERWALK ON HIWASSEE 130 ft. 157 ft. Gray Hard Granite
Physical Address,City,and Zip 157% 160 % LARGE FRACTURE 60 PIVT-d-- % _ n' f""
Cherokee 550200607510000 160 ft. 200 M Gray Hard!Granite
County Parcel Identification No.(PIN) 200 fL 305 fL Gray Hard'Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft'
(If well field,one tat/long is sufficient.) 21:,RIlYfi�RFiS _ enyire r `�rz��r�=t%11 `a
35.076528 N 83.993451 ;r BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certify o
7. Is this a repair to an existing well: No 12/19/2022
If this is a repair,fill out known well construction it forination and explain the nature ofthe Signature of C ' Well Contractor Date
repair under#21 remarks section or on the back ofthis form By signing this forni,I hereby certrfy that the wells)was(were)constructed in accordance
width 15ANCAC 02C.0100 or 15ANCrIC 02C-0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been prmdded to the well owner.
Formultiple injection ornon-water wells ONLPwith 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 ifneeessary.
9.Total well depth below land surface: 305 (ft)
Formultiple wells list all depths ifdi(jerent(example-3@ 200'and2 Q 1009 SUMTTTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion ofwell
10.Static water level below top of casing: 100
construction to the following:
If water lei eI is above casing use"+" j;
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 forth to the address in 24a
(i.e,auger,rotary,cable,directpush,etc.) above,also submit a copy ofthis fbimlvvithin 30 days of completion of well
construction to the following. I'
FOR ti1rATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpni): 60 Method of test: Air 24c.For Water Supply Injection Yells: 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 constriction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water i itv Revised Jan 2013
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