GW1-2023-02205_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES.
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON 38 ft. 40 ft.
Well Contractor Name 375 ft. 376 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESE MATERIAL
CHEROKEE WELL DRILLING 0 ft- 28 ft. 6.125 in. .188 Steel-black
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000718 FROM TO DIAMETER THICKNESq MATERIAL
List all applicable well construction pertmits Qe County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER THICKNES SLOT SIZEMATERIAL
Residential ft. ft. in.
ft. ft. in.
_ 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
`w s I ft. 20 ft.
Gravity-
ft. ft.
2023 ft. ft.
19.SAND/GRAVEL PACK(if applicable) {
FROM TO MATERIAL EMPLACEMENT METHOD 8c AMOUN
it. ft.
'
4. Date Well(s)Completed: 2/22/2023 Well ID# CAMP CREEK ESTATES ft. ft.ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
TOM&JENNIFER JACKSON 0 ft. 17 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 17 ft. 28 ft. Gray Hard Granite Set Casing
165 OLD WATERFALL RD MURPHY 28906 Lot CAMP CREEK ESTATE 28 ft. 38 ft. Gray Hard Granite
Physical Address,City,and zip 38 ft. 40 fL Gray Hard Granite Large Fracture 31 GPM
Cherokee 452500231623000 40 ft. 375 It. Gray Hard Granite
County Parcel Identification No.(PN 375 ft. 376 ft. I Gray Hard Granite Small Fracture 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 376 ft. 1405 ft.I Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.155759 N -84.281823 W BIT SIZE 5.98"
6. Is(are)the weti(s): Permanent
22.Z:111atipm
7. Is this a repair to an existing well: No 2/24/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under ff 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 15ANCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same 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: 405 (ft.)
For multiple wells list all depths ifd different(example-3@ 200'and 2 @ 1009 SUMITfAL INSTRUCTIONS
10.Static water level below top of casing: 10 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
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
(Le.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,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 36 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 ti a county health department of the county
where constructed.
Form GW-1 North Carolina Devarhnent of Enviromnent and Natural Resources -Division of Water Oualitv Revised Jan 2013