GW1--02817_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD j For Internal Use ONLY:
This form can be used for single or mutiple wells 4
1.Well Contractor Information 14.:}VATER'ZONE$. :.
FROM TO DESCRIPTION 1
WILLIAM LAWSON 175 ft. 176 ft.
Well Contractor Name 184 IL 190 ft_
NCW C3491 A 15:--.OUTER CASING(for ntidti-eased wells)OR LINER(if apphcable)I;
NC Well Contractor Certification Number FROM TO DIAMETER! THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft' 100 ft' 6.125 tin- SDR 21 PVC plastic
Company Name ft. ft. to
16:INNER-CASING.OR TUBING(geothermal dosed loop) ;; al
2.Well Construction Permit#: W2023000183 2023000182 FROM TO DIAMETER; THICKNESS MATERIAL
List all applicable well construction pertmits(ie Count,State,Variance,eta ft_ ft. io.
3.Weil Use: ft ft. in.
7:SCREEN -
FROM TO DIAMETER I THICKNESS SLOT SIZE MATERIAL
Residential fL ft. iit
ft.I ft. in.I .
18.GROUT • - ::�
... FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- ,-� k ► c L, 0 ft. 3 ft Bentonite Pelletts - - 50 - Gravity-
3 it 20 RentonitP slurry 150 Pumped/Positive Di
MAY 0 6 2024 ft. ft.
19 SAND/GRAVEL PACK(if applicable) '
h f Jr z Z F i:Fi>r.-.'".-x'°": kiRti FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[)W WOG+ ft. ft
ft. ft. I
4. Date Well(s)Completed: 4/10/2024 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JERYL GAHLHOFF 0 ft. 76 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 76 ft. 100 ft. Gray Hard Granite Set Casing
226 WALNUT CREEK TRL MURPHY 28906 Lot 100 ft. 175 ft. Gray Hard Granite . -
Physical Address,City,and Zip 175 ft. 176 ft: Gray Fractured Granite Small Fracture 2.GPM
Cherokee 442900871128000 176 ft. 184 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 184 ft. 190 ft. Gray Fractured Granite Fracture Zone 13 GPM
5b: Latitude and Longitude degrees/minutes/seconds or decimal degrees: 190 ft. 225 IL Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS' ',
35.000002 N -84.255126 W BIT SIZE 6.00" !;
6. Is(are)the well(s): Permanent '
22. Certification•
7. Is this a repair to an existing well: No 4/12/2024
+If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor I' Date
repair under#21 remarks section or on the back oft is form. -
___ _ ___,__- - By signing this fora I hereby certify that the.well(s)was.(were).constructed in accordance
with 15A NCAC 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 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: 225 (tit.)
For multiple wells list all depths ifdi(erent(example-3(4)200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: . Submit this fermiwithin 30 days of completion of well
10.Static water level below top of casing: 40 (ft_)
construction to the following:
If water level is above casing.use"+" Division of Water Quality,iInformation Procession Unit,
11. Borehole diameter: 6 (m.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection Wells: In addtiod to sending the form to the address in 24a
12. Well construction method: Rotary 1 i
(i.e.auger,rotary,cable direct push etc.) - above,also submit a copy ofthis form within 30 days of completion of well
construction to the following i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636-
i
13a. Yield(gpm): 15 Method of test: Air 24c.For Water Supply Injection Wells:1 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 Amotmt: 100 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