GW1--00273_Well Construction - GW1_20240105

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 I DESCRIPTION
WILLIAM LAWSON ft. ft-
Well Contractor Name ft. IL
NCWC3491 A 15.OUTER CASING(for multi-cased wefts)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER ' THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft- 60 ft- 6.125 iu' SDR 21 PVC plastic
Company Name ft. ft. m'
16.INNER CASING OR TUBING(geothermal dosed loop)
2.Well Construction Permit#: W2023000659
FRO I TO I DIAMETER 1 THICKNESS 1 MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. I ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
:FROM TO DI METER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. flt. ill.,
... l8 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
JAN 0 4 2024 0 ft- 3ft- Bentonite Pellets 50# Gravity
3 ft' 20 ft- Bentonite slurtty 150 Pum remie
a ss ign 7rnr 4(1 IL IL
(3y410/3000 �19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
ft. ft.
I
ft
4. Date Well(s)Completed: 12/22/2023 Well ID# HEALEY FIELDS SOUP 1
ft. R
5a. Well Location: &DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(le County,State,Variance,eta FROM ' TO DESCRIPTION(color,hardness,soil type,grain size,etc)
J MICHAEL WHITE LLC 0 ft. 34 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 34 ft. 60 IL Gray Hard Granite SET 60'CASING
572 OAKLAND LN ANDREWS 28901 Lot 60 ft. 327 ft Gray Hard Granite
Physical Address,City,aridZip 327 ft. 328 ft. Gray Fractured Granite SMALL FRACTURE
Cherokee 554603148705000 328 IL 600 ft- Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft'
(If well field,one lat/long is sufficient) it REMARKS
35.203568 N -83.883171 W BIT SIZE 5.89"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 12/28/2023
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 1 SA NCAC 02C.0100 or I SA 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 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: 605 (ft-)
For multiple wells list all depths ifdifferent(example-3(g 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: 200 (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 Mall Service Center,Raleigh,NC 27699-1617
12. Well constriction method: Rotary air 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): 0 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 Deoartment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013