GW1--05945_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.rWATER`ZONES' }. #
FROM TO DESCRIPTION
WILLIAM LAWSON 208 ft. 209 ft. I I -
Well Contractor Name 358 ft. 359 ft. I j
NCWC3491A 15 OUTER CASING(for multi=cased:wells)co LINER(if applicable) 1
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL •
CHEROKEE WELL DRILLING 0 ft. 48 ft. 6.125 in" SDR 21 PVC plastic
Company Name ft. ft. I, in.
16.:INNER-CASING OR TUBING(geothermal closed-loop) ,
2.Well Construction Permit#: 0467 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc. ft. ft. I in.
3.Well Use: ft. ft. j; •
in.
1-7 SCREEN' • .. ,
FROM TO ` DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. 1 -in. '
18:GROUT_' '�•" i-
" - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
. .,.•. , --• - 0 ft. 3 ft. Bentonite Pellrtts 50 Gravity
1 "-ti;7(.t,,.j ,.;; r• '1"..... • 3 ft. 20 ft. Bentonite"slurry 200 Pumped/Tremie
• 0 C T 0 9 2024 19.SAND/GRAVEL PACK(if applicable) _ ' i
:� 7-r r t,� ',, -FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
IrfiJ:r M,1:f:�•.. t ft. ft.
WailSOG
ft. ft.
4. Date Well(s)Completed: 2/22/2024 Well ID#
ft. ft.
5a. Well Location: .'
20.DRILLING LOG. (attach'additional sheets if necessary)
List all applicable well construction permits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ALLAN SWIRES Oft. 22 ft. Brown.Medium Slate
Facility/Owner Name Facility ID(if applicable) 22 ft. 48- ft. Gray Hard Granite Set Casing
180 HICKORY ROCK RD BRYSON CITY 28 Lot 2 48 ft. 208 ft. Gray Hard Granite
Physical Address,City,and Zip 208 ft. 209 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Swain 656900182920 209 ft. 358 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 358 ft. 359 ft. Gray Fractured Granite Large Fracture 30 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 359 ft. 385 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS.
35.311961 N -83.489758 w BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certificatio . 4 ,
7. Is this a repair to an existing well: No 2/23/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certifie Well Contractor _ _ - - - -
-repair under it 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 15A NCAC 02C.0100 or 15A NCAC 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: 385 (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: 120 (ft.) construction to the following:
Ifwater level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I;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: I '
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 30 Method of test: - Air • 24c.For Water Suavity 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: . 0 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 oil Water Oualitv Revised Jan 2013
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