GW1--07238_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
['his form can be used for single or mutiple wells-
14.WATER ZONES -- • '1,f y i
I.Well Contractor Information:
FROM TO DESCRIPTION ,
(VILLIAM LAWSON 190ft. 191 ft.
Well Contractor Name ft. ft.
NCWC3491A 15.OUTER CASING(for multi=cased wells)OR LINER(if applicable) _{
4C Well Contractor Certification Number FROM TO DIAMETER ! THICKNESS MATERIAL
;HEROKEE WELL DRILLING 0 ft• 120 ft 6.125 ln• , SDR 21 PVC plastic
L'ompany Name ft. ft. hi.
16.INNER CASING'OR TUBING(geothermal closed loop)•
:.Well Construction Permit#: W2023000538 FROM TO DIAMETER , THICKNESS MATERIAL
;ist all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft. in. ,
I.Well Use: ft. ft. in. 1'
17.SCREEN : • •..• . 1
FROM TO DIAMETER THICKNESS SLOT SIZ MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
. , •'1%,a c ;; ki g,'?•a 0 ft. 3 fh Bentonite Pelletts 10(1 Gravity
NOV 2023 3 ft. 2Oft Bentonite slurry ft. ft. 700 Pumped/Tremie
•mry(.30.
19.SAND/GRAVEL PACK(if applicable) 1
lrc I=`� • • FROM TO MATERIAL i . EMPLACEMENT METHOD&AMOUN
Gt..�' ft. ft. i
ft. ft.
I. Date Well(s)Completed: 10/25/2023 Well ID# HIWASSEE CREEK EST ft. ft.
;a. Well Location: . .,, ; . '20.DRILLING LOG;(attach additional sheets if necessary) ' -
;ist all applicable well construction pertmits(ie County,State,Variance,etc. :FROM ' TO ! DESCRIPTION(color,hardness,soil/rock type,grain Size,etc)
1OBERT.ELDER :.;,,,).!. ; , :TR 11-A•. , •.'0 ft. 102 -"It:' •Brown Medium Slate ' '
7acility/Owner Name Facility ID(if applicable) 102 ft. 120'" ''ft.)`Gray'Hard Granite"SET.120'CASING'-
iIWASSEE:CREEK,ESTS TR 11A MURPHY 28906 Lot 11A HIWASSEE CREEK ESTS 120ft. 190' 'ft. 'Gray Hard Granite
?hysical Address,City,and,Zip• 1,90 ft. 191:, ';ft:; Gray,Fractured,Granite SMALL FRACTURE 2 GPM
2herokee,.•.: „, . , . - . . 455200918651000 191,ft. 585 ft. -Gray Hard Gran to . .
:ounty Parcel Identification No.(PIN) ft. , .ft. ,• . .1.
ib. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
If well field,one lat/long is;sufficient.) 21,REMARKS'''
35.074295 N -84.149147 W BIT SIZE 5:97" i '
S. Is(are)the well(s): . Permanent I
22. CerHP ati "
7. Is this a repair to an existing well: No ; „ 11/2/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of edified Well ntractor . 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.
di 23, Site a ram or additional well details:
For multiple injection or non-waterwells ONLY with the same construction,you can , •• g
•
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: 585 (ft.) I
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS I
' 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: I
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 air 24b.For Injection Wells: ; In,addtion.toi 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 39 days.of,p9mpletion of well _•,,
constriction to the following: ' 1 "
FOR WATER SUPPLY•WELLS ONLY:.• ._. • '`Division'of Water Quality,Undergroun Injection Control Program,
:-163&Mail'Service Centel•,Raleigh,NC 276994636
13a.Yield(gpm): 2 Method of test: , , Air 24c.For Water Supply`lniectionWells • 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: 25 completion of well construction to the'cot nty-health,department of the county
where constructed.
Form GW-1, . North Carolina Department of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013