GW1-2023-01894_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4.-W_ATER ZONES.,
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON 187 fL 188 ft.
Well Contractor Name 295& 298 ft.
NCWC3491 A. 15.OUTER CASTING(for multi-cased wells)OR LTiVER'(ifapplicaUle):.:._ 1
NC Well Contractor Certification Number FROM TO D THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 160 fL 6.125 in- SDR 21 PVC plastic
Company Name ft. ft.
16.INRTR CASING OR TUBING(geothermal closed loop)
2.11rell Construction Permit#: W2023000007 2022000590 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(fe County,State,irariance,etc fL ft.
3.Well Use: ft. ft. in
17:SCREEN_- ----
• FROINI TO DL4�vIETER THICKNESS SLOT SIZE VJATERL4L
Residential ft. ft. IIL
fL fL
I&GROUT
o •+^ FROM TO MATERIAL; EMPLACEMENT V4RTHOD&AMOUNT
a '. ALL' 0 ft 20 ft- Bentonite Pelf fts Graft
ft. ft.
FEB 2 2 2023 ft. ft.
l!r i; 1%SAND/GRAVELPAC-K(ifapplicable)
FROVi TO MATERIAL EMPLACENIENT METHOD&AMOUNT
�tamr Qi uO%:
ft. fL
4. Date 1Vell(s)Completed: 2/14/2023 1Vell ID# MARY IQNG MTN
ft. ft.
5a. Well Location: 20.DRILUNG LOG(attach additional sheets if necessary)
List all applicable well constriction pertmits lie County,State,Variance,etc FROM- TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
CLINTON HENDERSON/CHASITY WIKE TR 61-A 0 M 138 ft. Brown Medium Slate
Facility/Owner Name Facility ID(ifapplicable) 138 ft. 160 ft. Gray Hard Granite Set Casing
114 AUTUMNBROOK TRCE MURPHY 28906 Lot 160 ft. 187 fL Gray Hard Granite
Physical Address,City,and Zip 187 ft 188 ft. Gray Hard.Granite Small Fracture 1 GPM
Cherokee 458000586013000 188 ft. 295 ft. Gray Hard,Granite
County Parcel Identification No.(PIN) 295 ft. 298 fk Gray Hard;Granite Large Fracture 26 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 298 ft 325 R Gray Hard:,Granite
(If+ve11 field,one lattlong is sufficient) 21.REl•LARKS
35.039482 N -84.060897 W BIT SIZE-5.99"
j �
6. Is(are)the well(s): Permanent
22. Certificatio I
A�A�
7. Is this a repair to an existing well: No2/16/2023
If this is a repair,fill out known well construction information and explain the natm a of the Signature of Certified Well Contractor ate
repair under#21 remarks section or on the back of this form By mgmng thisforw,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 ff'ell Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple h jection or non-water wells ONLY math the same construction,you can 23. Site diagram or additional well details:
submit one form[ You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
9.Tofid well depth below Lind surface: 325
For multiple wells list all depths ifeli ferent(example-3@ 200'and 2 @ 100) SUMTTTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft.)
24a.For All 1Vells: Subunit thi�s form within 30 days of completion of well
If water loved is above casing,use construction to the following: 1;
Division of Water Qnality,Information Procession Unit,
11. Borehole diameter: 6 (in) 1617 Mail Service,Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection 1Vells: hi addtitin to sending the fonn to the address in 24a
(i.e.auger•rotary,cable,direct push,etc.) above,also submit a copy ofthis form ivithin 30 days of completion of well
construction to the following: I 1
FOR 1VATER SUPPLY WELLS ONLY: Divisioni of Water Quality,�Undertrgroun Injection Control Program,
1636-Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 27 Method of test: Air 24c.For Water Supply Injection R`cils:- In addtion to sending the form to
the address(es)above,also submit orie i;opy ofthis form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion ofwell construction to the ci inty health department ofthe county
where constricted.
Form MV-1 North Carolina Denatinient of Environment and Natural Resources -Division of Water Ouahty Revised Jan 2013