GW1--03336_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON
200 ft. 203 ft.
Well Contractor Name ft. ft.
NCW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) i
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 90 6.125 hL SDR 21 PVC plastic
Company Name ft' ft' hi'
[16.I INNER CAS11R TUBING(geothermal closed loop)
2.Well Construction Permit ii: W2024000189 FROM ! TO DI A.\1ETER THICKNESS ! MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft. r. in.
3.Well Use: ft ft. ! hi.
17.SCREEN
FROM ! To DIAMETER THICKNESS 1 SLOT SIZI. MATERIAL
Residential ft. ft. in
ft ft. in. j
pl.GROUT 1
kr FROM TO MATERAAl. ' EMPLACEMENT METHOD&AMOUNT
4....,.�, t. .i ty 0 ft' 3 ft' Bentonite PeIlet3s 50 Gravity
3 ft 20 it Bentonite slurry 150 Pumpeed/Tremie
aUll v : 2024 ft ft
19.SAND/GRAVEL PACK(If applicable)
If+f0.'I+Sw:w f`' .f7 •"g 1✓pit FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
MiCell:A,1 ft. ft
4. Date Well(s)Completed: 5/13/2024 Well IDtt ft ft.
ft. ft.
5a. Well Location:
keh additional necessary) iiii4:711
List all applicable well construction pertmits(te County,State.Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock
type,grain size,etc)
TRAVIS&BETH DECKER
O ft. 68 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 68 ft. 90 ft, Gray Hard Granite St Casing
417 WELLS RD MARBLE 28905 Lot 90 IL 200 ft. Gray Hard Granite
Physical Address,City,and Zip 200 ft. 203 ft. Gray Fractured Granite Fractured Zone 3 GPM
Cherokee 551303297849000 203 ft. 300 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 300 ft. 505 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft'
(If well field,one lat/long is sufficient) 31.REMARKS
35.131801 N -83.976295 w BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certificati
7. Is this a repair to an existing well: No 5✓14/2024
If this is a repair;fill out known well construction information and explain the nature of the Sign ere of Certified Well Contactor Date
repair under#21 remm4s section or on the back of this form. By signing this form,I hereby certfv that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NC4C 02C.0200 WeII 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: 505 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 100 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (h.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 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,Undergroun Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 3 Method of test: Air 24c.For Water Snpply Injection Wells: In addtion to sending the farm 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 Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013