GW1--03655_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.`Nell Contractor Information: - -- -
FRONI J DESCRIPTION
WILLIAM LAWSON ft. ft.
Well Contractor Name ft. ft
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NCWC3491 A 15.OUTER CASING(for multi-cased dells)OR LINER(if applirnble)
NC-tell Contractor Certification Number FROM TO DIAME iMR. THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 126 ft' 6.125 in. .188 Steel-black
Company Name ft. ft. 'In.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000663 2022000313 FRONT TO DLAIvtETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie Count;State,Irariance,etc. ft. ft. in
3.Well Use: ft' ft' m
17.SCREEN
FROM TO DLANIETER THICKNESS SLOT SIZE MATERIAL
Residential it ft in.
ft. ft. in.
18.GROUT
FR .f TO MATERIAL El,]PLACEMENT METHOD&AMOUNT
0 ft. tit
ft. 20 ft. ISO PumoedM
MAY 2 2023 ft. ft.
Iin�GSAri. %l
1:r� 19.SAND/GRAXTL PACK(if applicable) =
FROM TO IvLATERIAL EA'II'LACEIv1ENY iA3ETHOD&Ail,IOUNT
ft. ft.
4. Date Well(s)Completed: 5/16/2023 Well ID# APPALACHIAN ESTATE ft. ft.
ft. ft.
5a. Well Location: 20.DRILLING LOG attach additional sheets if necessary)
List all applicable well construction pertwits(ie County,State.Var&mce,eta FROM TO DESCRIPTION(color,hardness,soillmck type,grain size,etc)
LUKE LINARES LOT 9 0 ft. 47 ft. Tan Medium Slate
Facility/OsimerName Facility ID(ifapplicable) 47 ft. 48 ft. Medium Sand&Gravel
283 SANDY GAP RD MURPHY 28906 Lot 48 ft. 102 fL Tan&Gray Medium Slate
Physical Address,City,and Zip 102 ft. 112 ft. Gray,Heaving/Quick Gravel&Sand
Cherokee 455100857300000 112 ft. 126 ft. Gray Hard Granite SET 126 CASING
County Parcel Identification No.(PIN)' 126 ft 305 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one latRong is sufficient) 21.REAIA RI S
35.055565 N -84.152685 W BIT SIZE 6.0"
6. Is(are)the well(s): Permanent zi
22. Certification:
7. Is this a repair to an existing well: No oIlu C�j /
!�ZZ,
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature ofCertitied el Contractor IDate
repair under 9 21 remarks section or on the back ofthis form By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15.4INCAC 02C.0200 l3•W Construction Standards and that a
8. Number ofwells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water wells OArLY with 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 if necessary.
9.Total well depth below land surface: 305
For nultiple wells list all depths ifdi,Jferent(example-3C 200'and 2 C 100) SLIA4ITT.4I INSTRUCTIOitirS
10.Static water Level below top of casing: 120 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Ifwater level is above casing,use"+" construction to the following:
Division of II ater Quality,Information Procession Unit,
11. Borehole diameter: 6 C'm.) 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.e.auger,rotary,cable,direct push,eta) above,also submit a copy ofthis 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): 0 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 ofthis form within 30 days of
13b. Disinfection type: HTH Amount: 10 completion of well construction to the county health department ofthe county
where constructed. j
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Fonn GW-I North Carolina Denartment of Environment and Natural Resources -Division of X-ater Oualih Revised Jan 2613
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