GW1--06566_Well Construction - GW1_20231006

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
WILLIAMLAWSON 58ft. 59 ft I
Well Contractor Name 113 ft. 114 ft 1
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 0 B• 40 B• 6.125 hi* SDR 21 PVC plastic
l .
Company Name ft' ft' m
16.INNER CASING OR TUBING(geothermal dosed loop) '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnrits(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.
4 r-' 18.GROUT
` `' + 9 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 B• 3 Bentonite Pell tts 50 Gravity
O( j 0 2023 3 ft. 20 ft. Bentonite slu 150 Pumped/Tremie
ll ,1;�?`'^ 19,SAND/GRAVEL PACK(if applicable) -
� ;i,�`�s,-lam
©�`^ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 9/7/2023 Well ID#
ft ft
5a. Well Location: • 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(le County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
BRENDA SUE MILLER 0 ft. 18 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 18 ft. 40 ft. Gray Hard Granite Set Casing
36 ROBS PLACE BRYSON CITY 28713 Lot 40 ft 58 ft. Gray Hard Granite
Physical Address,City,and Zip 58 ft. 59 ft Gray Hard'Granite Small Fracture 10 GPM
Swain 667500635571 59 ft. 113 ft. Gray Hard Granite .
County Parcel Identification No.(PIN) 113 ft. 114 ft. ' Gray Hard Granite Small Fracture 10 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 114 ft. 205 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.46286 N -83.447816 W BIT SIZE-5.90"
6. Is(are)the well(s): Permanent
-
22. Ceriifica• n-
7. Is this a repair to an existing well: No ` 9/12/2023 _
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Ce ed Well Contractor ate
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 1 SANCAC 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 bind surface: 205 (ft.) i
For multiple wells list all depths ifdi different(example-3Q 200'and 2 @ 100') SUivIITTAL INSTRUCTIONS 1
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 20 (ft.) i
If water level is above casing,use"+" construction to the following: ,I
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
r e auger,rotary,cable,directpush,etc.) above,also submit a copy of this forth'vithna 30 days of completion of well
C•�� g construction to the following: �I.
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,fUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 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 unty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan 2013