GW1--01420_Well Construction - GW1_20240301

I
WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or mutiple wells
14..WATERZONES__°:_
1.Well Contractor Information: ?
FROM TO DESCRIPTION
WILLIAM LAWSON 530 ft 531 ft
Well Contractor Name ft ft. I j
NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)'-
NC Well Contractor Certification Number FROM TO DIAMETER 1 THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 R• 30 IL 6.125 p h'• SDR 21 PVC plastic
Company Name ft j hi.
16.INNER CASING ORTUBING'(geotheamal closed loop) LL r
2.Well Construction Permit##: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State.Variance,etc. ff. ft I in.
3.Well Use: ft. ft. i,ni.
17.SCREEN
FROM TO DIAMETER' THICKNESS SLOT SIZE MATERIAL
Residential ft. ft f in.
ft. ft j,in.
18.GROUT - . _.
- - -- --FROM - TO - MATERIAL, - EIvWLACEK,IENI'METHOD&AMOUNT
1 !1�' 0 ft. 3 ft* Bentonite Pelts 50# Gravity
R R..C E I C) 3 R• 20 Bentonite slu 200 PumpedfTremie
MAK 0 1 202'4 19.SAND/GRAVEL PACK(if applicable) __
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Un
knforin a i no;toz'aW U&t ft. ft.
DWOtl' .
ft ft.
4. Date Well(s)Completed: 2/16/2024 Well ID## HICKORY ROCK FALLS
ft ft. I, ;
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary), -
List all applicable well construction pertnrits(ie County,State.Variance.etc. FROM TO DESCRIPTION(color,hardness,soi/rock type,grain size,etc)
ANDREW FRANCE LOT 15 0 f. 3 ft. Brown Soft Dirt
Facility/Owner Name Facility ID(if applicable) 3 ft. 6 ft. Brown Medium Slate
545 HICKORY ROCK FALLS RD BRYSON CITY 28713 Lot 6 ft 30 ft. Gray Hard,Granite SET CASING
Physical Address,City,and Zip 30 ft. 530 ft. Gray Hard,Granite
Swain 656900176569 530 ft 531 ft Gray Fractured Granite SMALL FRACTURE 0.25 GPM
County Parcel Identification No.(PIN) 531 ft. 785 ft Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. R
Of well field,one lat/long is sufficient) 21:REi1IARhS
35.308674 N -83.488765 W BIT SIZE 5.82" I
6. Is(are)the well(s): Permanent
22. Certification: tt /
7. Is this a repair to an existing well: No (ru 4"re t, 2/19/2024
Ifthis is a repair,fill out horown well construction information and explain the nature ofthe Signature of Certified Well Contractor Date _
repair under ti 21 remarks section or on the back of this fauna By signing thalami,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 5ANCAC 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 fonu 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 nerPssary.
9.Total well depth below land surface: 785 (ft.)
For multiple wells list all depths ifdii 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: 140 (ft.)
If water level is above casing use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mall Service Center,Raleigh,NC 27699-1617
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 fo !within 30 days of completion of well
construction to the following:
1
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality;Undergroun Injection Control Program,
1636 Mall Servic i Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0.25 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: 30 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 Quality Revised Jan 2013
;