GW1-2023-01895_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD For Literal Use ONLY: !,
This form can be used for single or mutiple wells
14.WAtER46NES r
1.Well Contractor Information: �-
FROM TO DESCRIPTION
WILLIAM LAWSON 157 ft. 159 ft.- ''
t
Well Contractor Name 186& 187 ft.
NCWC3491A Js'OUTERC.ASIPiG(forknii ti=casediielts):UItLINER(if p h ag 11g,
NC Well Contractor Certification Number FROM -ATO DIAMETER _ THICRIWS MATERIAL
CHEROKEE WELL DRILLING 0 B 45B 6.125 SDR 21 PVC plastic
Company Name B 1D
16 INNER CASING OR TUBING(geo#hermal closed loop)
2.Well Construction Permit#: W2022000693 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmlts(ie County.States Verriance.eta fL ft. in.
3.14'ell Use: % fit. in.
FROM TO DIAMETER THICKNF,S3 ISLOTSIZE MATERIAL
Residential flu ft.
fL fit. 1'; in.
FROM TO MATERIAL4 EMPLACEMENT METHOD&AMOUNT
fit.
<a
ft ft.v' d 3 Y
FEB ? 2023 19:sa�r,� R�� I'PAC1�(f p obi j
- -.- ,,.,__�__e..___.FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
!n;'vin:lu=1 ?l.:a •. �l�r„i tt. %
4. Date 1Vell(s)Completed: 2/13/2023 Well ID4���t806
% %
flu ft. I; '
Sa. Well Location: '0.°DRILLING;LOG(attach add146n3I sheets if necessary),; _
List all applicable well construction pertmuis(ie County,State,Variance,eta FROM TO DESCRIPTION(col&,hardness,soil/rock type,grain size,etc)
DAVID HINK Oft. 22 &. Brown Medium Slate
Facility/Owner-Name Facility ID(if applicable) 22 fL 45 & Gray Hard Granite Set Casing
110 BRITTON CREEK RD ANDREWS 28901 Lot 45 ft. 157 ft Gray Hard'Granite
Physical Address,City,and zip 157 ft. 159 ft. Gray Hard Granite Large Fracture 10 GPM
Cherokee 556600191323000 159flt. 186 tit Gray Hard Granite
County Parcel Identification No.(PIN) 186 ft: 187 ft. Gray Hard Granite Small Fracture 5 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 187 ft. 205 flu. Gray Hard Granite
(If well field,one lat/long is sufficient) 21,BIT SIZE-5.97"
35.218995 N -83.819644 W �
Ili
6. Is(are)the well(s): Permanent 22. Certificati i
7. Is this a repair to an existing well: No 2/15/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certifie Well Contractor'' Date
repair under#21 remarks section or on the back of this form_ B st n this orn;I her cem71 that the wells was were constructed in accom dance-
y Sm 8 f e4, . .fY (J (were)
with 1 SANCAC 02C.0100 or 1 SANCAC 02C.0200 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 same consbuction you can 23. Site diagram or additional well details:
submit one fora You may use the hack of this pagelto provide additional well site details or Ivell
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 205 010 a,
For multiple wells list all depths ifdii ferent(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: 80 (tt.)
construction to the following: I, j
Ifwater level is above casing,use"+" Division of Water Qudty,Iform»t n Pm-enn Tinit
...,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In addtion to sending the form to the address in 24a
(i.o:auger entry,cable;iliiect push etc.) above,also submit a copy of this fonmjwithin 30 days of completion of well
construction to the following: C I!
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality;Undergroun Injection Control Program,
1636 Mail ServicelCenter,Raleigh,INC 27699-1636
13a. Yield(glum): 15 Method of test: Air 24c.For Water Sup& Iniectiort Wells: In addtionto sending the form to
the address(es)above,also submit onelcopy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed. I!
Form GW-I North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised San 2013