GW1--04965_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 330 ft. 331 ft. j
Well Contractor Name 362 ft 363 R
NCWC3491 A 15.OUTER:CASING(for multi-cased wells)ORLINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER - THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 75 ft 625 ha• _188 Steel-black
Company Name ft. ft. in p�= 1 S%/��A Co ca._
16.INNER CASING OR TUBLNG(geothermal closed loop)"
2.Well Construction Permit#: W2023000336
FROM TO DIAMETER THICA-LIESS MATERIAL
List all applicable well construction per-Units(ie County.State,Variance,etc. ft. ft, in.
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3.Well Use: ft. in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.1
ft. ft. in.
E-} t�j 18.GROUT.
k f"'�1 /I„� .+ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
,
AUG 7 2023 0 ft, 20ft• Cnnrrete Gravity
ft. ft.
ft
,,�7rioi�,r+n'. 'fJ l:rid ft. ft.
f ` / 19.SAND/GRAVEL PACK(if applicable) I
FROM ' TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 7/3/2023 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) -
List all applicable well construction pertnuts(ie County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc)
MONICA KEASLER Oft_ 325 ft EXISTING WELL
Facility/Owner Name Facility ID(if applicable) 325 ft. 330 ft, Gray Hard Granite
179 CLONTS RD MURPHY28906 Lot 330 ft. 331 ft. Gray Fractured Granite SMALL FRACTURE 5 GPM
Physical Address,City,and Zip 331 ft. 362 ft Gray Hard Granite
Cherokee 454004929880000 362 ft. 363 ft. Gray Fractured Granite SMALL FRACTURE 5 GPM
County Parcel Identification No.(PIN) 363 ft. 405 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft' ft
(If well field,one lat/long is sufficient.) 21.REMARKS
35.02043 N -84.179465 W EXISTING WELL WAS 325 FT,DRILLED DEEPER FROM 325 FT TO 405 FT
6. Is(are)thewell(s): Permanent
• 22. Certifi . on•
7. Is this a repair to an existing well: No �� 7/23/2023
If this is a repair,fill out/mown well construction information and ecpl un the nature of the Signature of Certified Well Contractor Date
repair under#2l remarkss section Oran the back of this-form Br signing this our,I herebycerti that the well's was(were)constructed in accordance
Rm 3 / fy' t�
with 15.4 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 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: 405 (ft,)
For multiple wells list all depths ifditferent(example-5@200'and 2c 1100) SUMITTALINSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft.)
construction to the following:
I water level is above casing,s use"+" aMviston of Water Quality,Inferota!ian Procession Unit,
11. Borehole diameter: 6 (in.) 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,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 Mall Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 10 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: 20 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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