GW1--03773_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14-WATER ZONES
1.Well Contractor Information:
FRONI TO DESCRIPTION
WILLIAM LAWSON 261 ft. 262 ft-
Well Contractor Name 372 ft- 373 fL
i
NCWC3491 A la.OUTER CASING(for multi-cased-wells)OR LINER(if applicable}
-- - -
NC Well Contractor Certification Number FROh•I TO DIAMETER TMCKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 52 fL 6.125 SDR 21 PVC plastic
Company Name ft. ft in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.lVell Construction Permit#: W2023000083 W2022000399 FROIvf TO DIAMETER TFECKNESS NlATERL4L
List all applicable well construction pertmits(ie County;State,l'ariance,etc ft. fL in.
3.Well Use: ft. ft lIL
�17.SCREEN `
FROM TO DIAMETER TMCKNESS SLOT SIZE M,4TERLaI
Residential it ft UL
ft. ft. in.
^ ' - 18.GROUT
FROivi TO MATERIAL EMPLACEI•LENT METHOD&AA40U?JT
r, ft ft• onite Pellet
J U N V v M3 3 ft. 20 ft.
ft. fL
10.SAND/GRAVEL PACK(if applicable)
FRO\4 TO MATERIAL EA4PLACErNIENf METHOD&AIVIOUN1'
ft. ft.
4. Date Well(s)Completed: 5/12/2023 Well EN ft. ft.
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) -
List all applicable well construction permits(ie Count};State.I'ariance,etc FRO\f TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) .
JEFFREY MYNES 0 ft 23 ft. Red Medium Slate
Facility/Owner Name Facility IDiifapplicable) 23 ft. 52 ft. Gray Hard Granite SET 52 FT CASING
800 MARION ADAMS RD MURPHY 28906 Lot 52 tt 261 & Gray Hard Granite
Physical Address,City,and zip 261 fL 262 fL Fractured SMALL FRACTURE 2 GPM
Cherokee 452400257912000 262 ft. 372 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 372 fL 373 ft. Fractured SMALL FRACTURE 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 373 tt 405 fL Gray Hard Granite
(ffwell field,one laUleng is sufficient.)
21.RENLkRKS _
35.134557 N -84.278391 W BIT SIZE 5.97" -
6. Is(are)the well(s): Permanent
22. Certificatio
7. Is this a repair to an existing well: No 5i "4, ha�4���
If this is a repair,fill out brown well construction information and explain the nature ofthe Signature of Certi13 d167ell Contractor Date
repair under;`21 remarks section or on the bard ofthisform. By signing tlnsfam,I hereby certify that the well(s)was()4,ere)constructed in accordance
with 1 SA NCAC 02C.0100 or I SANCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 coyv ofthis 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 one form. You may use the back ofthis page to provide additional well site details or well
evnst ruction details. You may also attach additional pages ifnecessary.
9.Total well depth below land surface: 405
For multiple wells list all depths ifdii ferent(example-3@ 200'and 2 Gal 100) SUNIITTAL INSTRUCTIONS
10.Sufic water level below top of casing: 50 (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\later Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Nlail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In addfion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy ofthis formwithin 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): 4 Nlethod 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: 18 completion ofwell construction to the county health department ofthe county
where constructed.
Form GW-1 North Carolina Department of Emlrorunent and Natural Resources -Division of Water Oualitv Revised Jan 2013