GW1--06684_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells !
1.Well Contractor Informations 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 278ft. 279 ft. I .
Well Contractor Name 476 ft. 477 ft.
NCWC3491A 15.OUTER CASLNG(for multi-cased wells)OR LINER(if applicable) '
_:
NC Well Contractor Certification Number FROM TO DIAMEIEK! THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 140 ft. 6.125 j ill' SDR 21 PVC plastic
Company Name •
ft. ft. ! in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2024000291 5/23/2000 FROM 'TO DLAIvIETER THICKNESS MATERLAL
List all applicable well construction pertmits(ie Count};State,Variance.eta ft. ft. , in.
3.Well Use: it It - : in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft ft. in.
1&GROUT
77 pe. - - - -FROM- - 'TO -- '-'MATERIAL EMPLACEMENT METHOD&AMOUNT
t :,r t,,:L L. , •i a...,L..4 0 ft. 3 ft. Bentonite Pelletts 50 Gravity
3 ft. 20 ft Bentonite slurry 150 Pumped/Tremie
NUV082024 ft. ft.
r,e�, , , 1R5.4ND/GRAVEL PACK(if applicable)
--
1rr`.. i;:t:^ r ,tDi'�_ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
i 'r`uC%�::� ft. ft.
4. Date Well(s)Completed: 10/16/2024 Well ID# ft ft.
ft. ft. '
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie Count};State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RANDY CAVE 0 ft. 118 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 118 ft. 140 ft. Gray Hard,Granite Set Casing
3474 HYATT CREEK RD MARBLE 28905 Lot 140 ft. 278 ft. Gray Hard Granite
Physical Address,City,and Zip 278 ft. 279 ft. Gray Fractured Granite Small Fracture 1.5 GPM
Cherokee 552600064430000 279 ft. 476 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 476 ft. 477 ft. Gray Fractured Granite Small Fracture 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 477 ft. 505 ft. Gray Hard,Granite
(If well field,one lat/long is sufficient) 21.REMARKS -+
35.204821 N -83.955487 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent -
22. Certification:
7. Is this a repair to an existing well: No 10/17/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back ofthisform By signing this form,I herebycerti that the well(s)nos(were)constructed in accordance
b'm S .f .f'
with 15A NCAC 02C.0100 or 15ANC4C 02C.02001i 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: 505 (ft-)
For multiple wells list all depths ifdij9 rent(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: 60 (ft.)
construction to the following:
If water level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Services Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 24b.For Injection Wells: In addtien to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this Rain within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,lUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 3 Method of test: Air 24c.For Water Supply Injection Wells: In addtionto sending the form 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 Denartment of Environment and Natural Resources -Division of Water Duality Revised Jan 2013