GW1-2021-03148_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mutiple wells
4.-WATER70NESfx
1.Well Contractor Information: -FROM TO DESCRIPTION
WILLIAM LAWSON 153 M 154 ft.
Well Contractor Name 178 ft. 179 ft.
NCWC3491 A 15 OU7>RCASING(f r mitt cd webs)ONER(�ifa`p'a p gable
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 it 34 fL 6.25 'n• .188 Steel-black
Company Name ft. & in.
z16i'�1V R CASIN,G�UR UB_IN R(geofherm_al�asked „�,Nl .,�� �.
2.Well Construction Permit#: W2021000269 W2021000268 FROM i TTO rt DIAMETER: T1-11CKNFSJ MATERIAL
List all applicable well construction perimits ft County,State, Variance,etc ft. ft in
3.Well Use: t ft. m`
iP
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential � ft. ft. !in
% ft. ;n
Uqi\k 8 GROUT ' �:�� r.�
�CCfar�� FROM y/ .,. TO MATERIAL~ EMPLACEMENT METHOD&AMOUNT
t`l" «` �S�Jt,o 0 ft 0 ft
\� `'
ION
ft. ft
ft. ft.
9z /GRA EL ACK(if a ca le) J i
FROM�f~~ TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 6/28/2021 Well ID# HIWASSEE CREEK EST ft. ft.
ft. %
5a. Well Location:
0"�DRII,�LING�OG attach addih a eets ;n a
List all applicable well construction pertmits fie County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type gam size etc)
ROBERT ELDER TRACT 6 0% 10 ft. Brown Gravely Dirt
Facility/Owner Name Facility ID(if applicable) 10 ft. 34 ft. Gray Hard;Granite SET CASING
HIWASSEE CREEK ESTS MURPHY 28906 Lot HIWASSEE CREEK ESTATES 34 ft. 153 ft. Gray Hard lGranite
Physical Address,City,and Zip 153 ft. 154 ft. Fractured LARGE FISSURE 5 GPM
Cherokee 456200333033000 154 ft. 178 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 178 ft. 179 ft. Fracturedr SMALL FISSURE 1 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 179 fL 205 ft. Gray Hard Grande
4
(If well field,one lat/long is sufficient.) 1 REMIRK.IR I 1&1
35.07737 N -84.13908 W BIT SIZE 5.82"
6. Is(are)the well(s): Permanent
2(/�/ ,
7. Is this a repair to an existing well: No �
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 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 1 SA 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: 205 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 S UMITTAL INSTRUCTIONS
10.Static water level below top of casing: 0 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
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 Service Center,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 form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,f Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 6 Method of test: Air 24c.For Water Sunuly 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 Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Denartment of Environment and Natural Resources - Division of Water Oualitv Revised Ian 2013