GW1-2023-02464_Well Construction - GW1_20230404

1 I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZOAS__:..-:1.Well Contractor Information: LL ~
FROM TO DESCRIPTION
WILLIAM LAWSON 122 ft. 125 ft.
Well Contractor Name 155% 156 It. �
NCWG34991A 15.OUTER CEISI G(Airmulti-casedwells)(ALINER(>fapphrnhle)
- - - _
NC Well Contractor Certification Number FROM TO DIAMETER, TERCKNESS IJATF- AL
CHEROKEE WELL DRILLING 0 ft 120 ft. 6.125 in- SDR 21 PVC plastic
Company Name ft. It. in.
16.i�'ER CASING OR TUBING(geothermal closed loop)_
2.Well Construction Permit#: W2022000631 FROM TO DIAMETER T11ICKNESS MATERIAL
List all applicable well constriction pertnrits(ie Count,State.Pariarca eta ft ft. in.
3.Well Use: % ft
17.SCREEN
FROM TO DLAIIETER TI310,CNESS SLOT SIZE IVIATERLIL
Residential ft. f1 i1L
It. ft in.
18.GROUT _
y�
,. �
y T `•, ;i i 3 FRONT TO MATERIAL EMPLAM NTI 740D8s1040UNT4
l C u IJ, 3
�-• ft ft. tl:s 150 Gravi
pre ,► �t 2Q23 f. ft.
�rOcy~: 5 11. 19.SAND/GR.AYEL PACK(if applicable) _
i O i-''�;•""'v a�a iy:=,7 FROM TO MATERIAL F1,lPLACE�dENT\I.ETAOD&AMOUNT
ft ft.
ft -
4. Date Well(s)Completed: 3/24/2023 Well ID# 2394 NC HIGHWAY 60 ft.
ft. ft.
5a. Well Location: 20.DRI.LING I OG(attacliadditiatlal she:is if lieessSarV)
List all applicable well constnrction pertmits(ie County,State,Variance,etc. FRONT TO DESCRIPTION(color,hardness,soillrock type,gram size,etc)
TIM MILLS 0 it. 105 fL Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 105 ft 120 ft Gray Hard Slate SET CASING'
168 PURDY LN MURPHY 28906 Lot 120 ft. 122 ft Gray Hard Slate
Physical Address,City,and Zip 122 ft. 125 ft.- Gray Fractured Slate LARGE FRACTURE 30 GPM
Cherokee 446900168780000 125 ft 155 ft. Gray Hard Slate
County Parcel Identification No.(PIN) 155 ft 156 ft. Gray Fractured Slate SMALL FRACTURE 20 GPM
5b. Latitude and Longitude degreeshninutes/seconds or decimal degrees: 156 ft. 205 ft. Gray Hard Slate
(If well field one latflong is sufficient) 2L RENI[ARICS i
----
35.005672 N -84.139047 W BIT SIZE 6.0"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 3/27/2023
Ifthis is a repair,fell out known well construction information and explain the nahire ofthe Signature ofCertiii Li ell Contractor Date
repair under 4 21 remarks section or on the back ofthis four. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA r\rCAC 02C.0100 or 1:A AfCAC 02C.0200 iYell Construction Standards and that a
8. Number ofwells constructed: 1 coyy oftns record has been yrm-ruled to the well owner.
For multiple injection or non-water wells ONLY itzth the same construction,you can 23• Site diagram or additional well details:
submit ore fore 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.Total well depth below land surface: 205..
For multiple wells list all depths ifdi SUAIITTAL INSTRUCTIONSJ a
10.Static water level below top of casing: 60 (ft) 24a.For All ZVeRs: Submit this form v thin 30 days of completion of well
construction to the following:
If u ater level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (11L) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well constructionmethod: Rotary air 24b.For Iniection'Wells: In adtftion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form vvrithiri 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(-,pm):' 50 Method of test: Air 24a For Water Sunnty 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: 10 completion of well construction to the county health department ofthe county
where constricted
Form GINLI North Carolina Deoarhnent ofEnvironment and Natural Resources -Division of Water Oualitv Revised Jan 20I3