GW1--01305_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells •
1.Well Contractor Information: 14.WATER-ZONES -- - - 4.-„ ,,
FROM TO DESCRIPTION
WILLIAM LAWSON 137 ft. 138 ft. ! ,
Well Contractor Name 155 ft. 156 ft.
N CWC3491 A 15,OUTER CASING(formulti-rased hells)OR LINER(if apphcable)
NC Well Contractor Certification Number FROM TO DIAMETER: THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 it 45 It 6.125 I in' SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING ORRTUBpiG;:;(geothermal ciosealloo ) °''dd :
2.Well Construction Permit#: 022-1377 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State.Variance etc. ft. ft. in.
3.Well Use: ft. tit in.
17:SCREEN:--:: _ ---- _-7-w: ,-__;_ -- <.--I'
FROM TO DIAMETER THICKNESS SLOT STZF MATERIAL
Residential ft. ft , in.
ft- fL , in.
- - -- - --- . . - -- - -18:GROUT '`": .,. _. .
• ••[Ion%d"fl FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
�� + .L! 0 it. MATERIAL
tL Bentonite Pell tts 50# Gravity
�'t� 2 2��� 3 ft. 20 Bentonite slu 200 Pumped/Tremie
ft. ft.
hgormatien Pt;FaflE',P.sq 19.SAt�1D/GRAVEL PACK(if;applicable) =
BOO FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
ft- ft 1
4. Date Well(s)Completed: 11/6/2023 Well ID# OLD HWY 64E-LOT 8 ft- f
ft. ft 1
5a. Well Location: 20 DRILLING LOG(attiich 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)
THOMAS HUSEREAU 0 R 20 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 20 ft. 45 ft. Gray&White Hard Granite SET 45'CASING
OLD HWY 64 E HAYESVILLE 28904 Lot 45 ft. 137 ft: Gray&White Hard Granite
Physical Address,City,and Zip 137 ft. 138 ft. Fractured SMALL FRACTURE 3 GPM
Clay 548900766237 138 ft. 155 ft. Gray&White Hard Granite
County Parcel Identification No:(PIN) 155 ft. 156 ft. Fractured SMALL FRACTURE 13 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 156 ft 205 ft. Gray&White Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS`. .
35.021881 N -83.719416 W BIT SIZE 5.99" ,
6. Is(are)the well(s): Permanent t
22. Certification:
7. Is this a repair to an existing well: No `. 11/15/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Veil Contractor I 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 SANCAC 02C.0100 or 15ANCAC 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 sameconstruction,you can 23. Site diagram or additional well details:
submit one form. You may use the back ofthis page to provide additional well site details or well
construction details. You may alsoiattaclt additional pages if necessary.
9.Total well depth below land surface: 205 (ft.)
For multiple wells list all depths if different(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: 20
If water level is above casing,use"+" ft construction to the following: I, '
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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12. Well construction method: Rotary air 24b.For Injection 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,fUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a. Yield(gpm): 16 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: 125 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 Revised Jan 2013
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