GW1--03531_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For hternal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: �'' :"
FROM TO DESCRIPTION
WILLIAM LAWSON 188 ft. 189 ft.
Well Contractor Name
n ft.
NCWC3491 A 15.OUTER CASING(for multi rased wells)OR LINER(ifs
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 it• 80 ft' 6.125 0' SDR 21 PVC plastic
Company Name ft ft
NE INNER CASING OR TUBING(geothermal dosed loop)
2.Well Construction Permit#: W2023000588 E 0 P I•RoM TO DIAMETER THICKNESS 1 MATERIAL,
List all applicable well construction pertntits(ie County,State.Variance,etc ft. ft. in
3.Well Use: ft. ft. in
17.SCREEN
FROM 1 TO r DIAMETER THICKNESS 'SLOT SIZE MATERIAL
Residential r ft. ft. in.
I ._
ft. ft. in.
i
��, 18.GROUT i N
"a:.. *`J] D FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
O ft a ft Bentonit ra
e Pelletls 50 Gvity
J U N 1 2 2024
3 ft' 20 ft. Bentonite slurry 150 Pumped/Tremie
ft. ft.
i R +M 01•�1icit
19.SAND/GRAVEL PACK(if applicable)
i
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 4/22/2024 Well ID#
ft. i ft.
5a. Well Location: 20.DRILLING ,
List all applicable well construction pertmits lie County,State,Variance,etc. FROM TO ' DESCRIPTION(color,hardness,soil/rode type,gain size,etc)
DARNELL HOUFEK - 0 ft. 59 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable)
59 ft. 80 ft Gray Hard Granite Set Casing
9 PINEY RIDGE DR MURPHY 28906 Lot 80 ft 188 ft Gray Hard Granite
Physical Address,City,and Zip 188ft. 189 It. Gray Fractured Grande Small Fracture 10 GPM
Cherokee 455003447703000 189 ft. 200 ft. Gray Hard Granite
County I'tu,:rll dolt Ili cat ton No.(PIN) 200ft. 245 ft. Gray Hard Granite
5b. Latitude and Longitude degrees/minutes/seconds or dechnal degrees: ft I ft.
(If well field,one latflong is sufficient.) 121.REMARKS
35.027817 N -84.164138 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certification
7. Is this a repair to an existing well: No 4/23/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certit Contractor Date
repair under#21 remarks section or on the back of this form.
By signing this form,I hereby certifi'that the well(s)'ens(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NC4C 02C.0200 Well Construction Standards and that a
S. 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: 245 (ft.)
For multiple wells list all depths if different(example-3(§200'and 2(0 1009 SUMITTAL INSTRUCTIONS
24a.For AB Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft.)
construction to the following:
If water level is above casing use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (im.) 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 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 10 Method of teat: 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
13k Dbhrfecton 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