GW1--06685_Well Construction - GW1_20241108

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 195 ft. 196 ft.
Well Contractor Name 288 ft. 289 ft. I 1
NCW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMEItilt' THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft• 87 ft' 6.125 i hi* SDR 21 PVC plastic
Company Name ft ft in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2024000525 2024000028 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County;State,Variance,etc. ft. ft. 'in.
3.Well Use: ft. ft in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. • . in.
ft. ft_ in.
% '' 7-'' '. `t..•., : : 18.GROUT
•`s.'+a "=�.e'4.•"" '1 ' a'•'; FROM-- TO --MATERIAL - - -EMPLACEMENT METHOD R:AMOUNT- - - -
NOV S 2024 0 ft. 3ft. Bentonite Pell 50 Gravity
3 ft 20 ft. Bentonite slu 150 Pumped/Tremie
rr .0 I r}?Aft. ft
C;i1g;;?1104.23 19:SAND/GRAVEL-PACK(if applicable) ,'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft_ i.
4. Date Well(s)Completed: 10/24/2024 Well ID#
ft. ft. •
•
Sa. Well Location: 20.DRILLING LOG G(attach additiorralsheets if necessary)
List all applicable well construction pertmits(ie Counts,State,Variance,etc. FROM TO ' DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
TIMOTHY S SMITH 0 ft. 53 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 53 ft. 87 ft. GrayHard:Granite Set Casing
310 MORROW RD MURPHY 28906 Lot 87 ft. 195 ft- Gray Hard;Granite
Physical Address,City,and Zip 195 ft. 196 ft. Gray Fractured Granite Small Fracture 1 GPM
Cherokee 454600053370000 196 ft. 288 ft. Gray Hard'Granite
County Parcel Identification No.(PIN) 288 ft. 289 ft. Gray Fractured Granite Small Fracture 7 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 289 ft. 325 ft. Gray Hard,Granite
(If well field,one lat/long is sucient) 21.REMARKS -
ffi
35.191086 N -84.222795 w BIT SIZE-5.54" ,
I
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 10/30/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified t re Contractor Date
repair ender 21 remarks section or on the back of this form. BY signing this form.I hereby certii that the well(s)was(were)constructed in accordance
with 15AuNCAC 02C.0100or 15ANCAC 02C.0200Well 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: 325 (ft.) j
For multiple wells list all depths ifdii/different(example-3C3a 200'and 2l 100') SUD'II'ITAL INSTRUCTIONS
10.Static water level below top of casing: 100 (ft.) 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 (in.) 1617 Mail Service1Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 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 fone 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): 8 Method of test: 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
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 Ouality Revised Jan 2013