GW1--04795_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i
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This form can be used for single or mutiple wells
1.Well Contractor Information: 14,WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 224 ft. 225 ft.
Well Contractor Name 232 ft. 235 ft.
NCWC3491A 15.OUTER CASING(for multi-cased_wells)OR LINER(if applicable) j
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 fL 43 ft. 6.125 1 in. SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING;(geothermal closed loop)
2.Well Construction Permit#: W2023000078 2022000763 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie County,State,Variance,etc. ft. ft. ' in.
3.Well Use: ft. ft. . in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
RECEIVED
_FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft. Bentonite Pellettc 150 Gravity
JUL `'a 1 2023 ft. ft.
ft. ft.
Gtil4Dii PfeCietlirs.Unit 19.SAND/GRAVEL PACK(if applicable)
CAVOiSOG FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 6/6/2023 Well ID# CANDY MTN HGTS
ft. ft.
5a. Well Location: 20.DRILLING LOG_ (attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
DAVID CHOAT LOT 18 0 ft. 31 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 31 ft. 43 ft. Gray Hard Granite Set Casing
353 CANDY MOUNTAIN HGTS MURPHY 28906 Lot 18 43 ft. 224' ft. Gray Hard Granite
Physical Address,City,and Zip 224 ft. 225 ' ft. Gray Hard Granite Large Fracture 10 GPM
Cherokee 453200733086000 225 ft. 232 ft. Gray Hard Granite
County - Parcel Identification No.(PIN) 232 ft. 235 ft. Gray Hard Granite Large Fracture 20 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 235 ft. 265 ft. Gray Hard Granite
(If well field,one 1at/long is sufficient.) 21.REMARKS ' i
35.07415 N -84.225128 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No j� 6/7/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certifie ell Contractor Date
repair under#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 15A NCAC 02C.0200 Well Construction Standards and that a
8. 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 one form. 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: 265 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For AU Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 100 (ft.)
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 Injection Wells: In addtion 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 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
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13a. Yield(gpm): 30 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: NTH Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013 •
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