_Well Construction - GW1_20230327 (13)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 208 ft. 210 ft.
Well Contractor Name 231 ft. 233 ft
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) j
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 44 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#: W2023000020 2022000766 FROM TO DIAMETER TMCKNES MATERIAL
List all applicable well construction pertmits rie County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN i
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft in.
ft. ft. in.
2 18.GROUT
a ^'-^5 .y FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
M ft. ft.AR 2 7 2023
ft. ft
19.SAND/GRAVEL PACK(if applicable) j
FROM TO MATERIAL IIvIPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 3/10/2023 Well ID# ft. ft.
ft. ft.
5a. Well Location:
20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(re County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
JANET KARDOKUS Oft. 15 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 15 ft. 44 ft. Gray Hard Granite Set Casing
865 KILBY RD MURPHY 28906 Lot 44 ft. 208 ft. Gray Hard Granite
Physical Address,City,and zip 208 ft. 210 ft. Gray Hard Granite Large Fracture 25 GPM
Cherokee 457600061733000 210 ft. 231 ft Gray Hard Granite
County Parcel Identification No.(PIN) 231 ft. 1233 ft Gray Hard Granite Large Fracture 10 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 233 ft. 1245 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS '
35.198919 N -84.122933 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certif, Noon•
7. Is this a repair to an existing well: No rti � 3/13/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Coatrfctor 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.0100 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the saute construction,you can 23. Site diagram or additional well details:
submit oneform. 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: 245 (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: 60 (ft.) construction to the following: " '
If water 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 24b.For Iniection 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 fomt within 30 days of completion of well
construction to the following: I ,
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 35 Method of test: Air 24c.For Water Suoniv Iniection 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 theicounty health department of the county
where constructed. I
Form GW-1 North Carolina Department of Enviromnent and Natural Resources - Division of Water Ouaiitv Revised Jan 2013