GW1--05964_Well Construction - GW1_20230912

II
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: i4..�XATER ZONES_.:,=: s
FROM TO DESCRIPTION
WILLIAM LAWSON 324 ft. 325 ft. I I
Well Contractor Name 364 ft 365 ft 1 I
.-sa sr
NCWC3491A 15.OUTER CASING(for;mnitiieasedEwells)ORLINER(il?"apphcable) _, .
NC Well Contractor Certification Number FROM TO DIAMETER Itliel"NESS MATERIAL
CHEROKEE WELL DRILLING 0 it 40 it 6.125 ; in. SDR 21 PVC plastic
ftCompany Name ft. m
16.INNER CASING OR TUBING(geothermal closed loop) . • -2
2.Well Construction Permit#: W2023000056 2023000006 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perimits(ie County State,Variance,eta 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.
- -s� �ED •
IS.-GROUT.-: - - --._''
r} I.— IL..i'. ,r FROM) TO MATERIAL EMPLACEMENT METHOD&AMOUNT
2�23 0 ft 3 ft. Bentonite Peiletts 50 Gravity
SE P 1 3 ft 20 ft' Bentonite slimy 150 Pumped/Tremie
,era c,cPIT:C A
vitIOPam, It. ft
lt1�o" r 19:S_YD/GRAVEL_PACK(if ap tlicable)- -� =-,_ �-
FROM TO MATERIAL; EMPLACEMENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 7/12/2023 Well ID# ft.
ft. ft. I
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)List all applicable well construction perimits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soilhock type,grain size,etc)
FRED LADUE 0 ft 23 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 23 ft 40 ft. Gray Hard Granite Set 40'Casing
301 BAKER RD MURPHY 28906.Lot 40 ft. 324 ft. Gray Hard Granite
Physical Address,City,and Zip 324 ft 325 ft. Gray Fractured Granite Small Fracture 6 GPM •
Cherokee 452200551171000 325 ft. 364 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 364 ft 365 ft. Gray Fractured Granite Small Fracture 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 365 ft. 405 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 2L REMARKS
35.078314 N -84.267102 W BIT SIZE-5.97" ii
i '
6. Is(are)the well(s): Permanent
22. Certificatio
7. Is this a repair to an existing well: No nr ,1 7/17/2023
Iftlns ii•a"repaii,fihl 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 thisforu4 I hereby certfy that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or15ANCAC 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: 405 (ft.)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (ft.)
construction to the following:
If water level is above casing use'+"v
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 addtioti to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push etc.) 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 Ceirter,Raleigh,NC 27699-1636
13a. Yield(gpm): 8 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the fonn to
the address(es)above,also submit one copy of this fonn 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 Oualitv 1 Revised Jan 2013