GW1--05100_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON 68 ft. 69 ft.
Well Contractor Name 192 ft. 193 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING Oft. 55 ft• 6.125 ill. SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop) ;
2.Well Construction Permit#: W2023000160 2023000159 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(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
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1��-^^• d"'11,i_ 70La 17. 0 ft. 3 ft. R. oni P Il s 50 Gravi
L"F_ t CM,,,
F. 3 ft. 20 ft. BPntonite chirry 150 Piimped/Tremie
ft. ft.
AUG 0 A 2023 • 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
it`n'4:r i, c.n Prr•�:.s+4:'1 UrI ft. ft.
ft. ft.
4. Date Well(s)Completed: 7/13/2023 Well ID#
ft. ft.
Sa. 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)
LIAM&PATRICIA YOUNG Oft. 36 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 36 ft. 55 ft. Gray Hard Granite Set Casing
2710 RIVER HILL RD MURPHY 28906 Lot 55 ft. 68 ft. Gray Hard Granite
Physical Address,City,and Zip 68 ft. 69 ft. Gray Hard Granite Small Fracture 3 GPM .
Cherokee . 452500907924000 69 ft. 192 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 192 ft. 193 ft. Gray Hard Granite Large Fracture 9 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 193.ft. 225 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS ,
35.14971 N -84.255551 W BIT SIZE-6"
6. Is(are)the well(s): Permanent 22. Certifi do
7. Is this a repair to an existing well: No ,014/.4---------- 8/2/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well 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 oneform. 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: 225 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS •
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:
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 Infection 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
13a. Yield(gpm): 12 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: 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 Duality Revised Jan 2013