GW1-2021-03627_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
T---..._ --
FROM _._.._ -- - - - --- ---------
O DESCRIPTION
WILLIAM LAWSON 262 ft. 263 ft
Well Contractor Name ft ft
NCWC3491A 15.OUTER CASING(for multi4ased wells).OR LINER(if applicable). .
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft 100 ft- 6.125 in- SDR 21 PVC plastic
Company Name ft ft in.
16.INNER CASING%OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2021000354
FROM TO DIAMETER I MCKNES MATERIAL
List all applicable well construction perimits(se County,State,Variance,etc. ft ft
3.Well Use: ft ft
17.SCREEN
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential . ft ft in.
ft ft in.
c �
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
S {• v p ft 20 ft Bentonite Pell tM ISO Gravity
.•,�C��� t e���� ft ft
ft ft
19.SAND/GRAVEL PACK(if applicable):
V� 'i FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft ft
ft ft
4. Date Well(s)Completed: 7/9/2021 Well ID# JACKSON STILES
ft ft
5a. Well Location: 20.DRILLING LOG'(attach a0ditional sheets if necessary)
List all applicable well construction pertmits rie County,State,Variance,etc. F----- ----:- -_._ size etc)
RICKEY JOE STILES FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc)
5408 US 19 0 ft 3 ft Black Stilt Dirt
Facility/Owner Name Facility ID(if applicable) 3 ft 82 ft Gray Medium Slate
5410 US 19 MARBLE 28905 Lot 82 ft 100 ft Gray Hard Granite SET CASING
Physical Address,City,and Zip 100 ft 262 ft Gray Hard Granite
Cherokee 551404533244000 262 ft. 263 ft Fractured SMALL FISSURE 0.25 GPM
County Parcel Identification No.(PIN) 263 ft 605 ft Gray Hard Granite
5b. Latitude and Longitude degrees/minates/seconds or decimal degrees: ft fk
(If well field,one tat/long is sufficient.) 21.REMARKS
35.140498 N -83.968269 W BIT SIZE 6.01"
6. Is(are)the well(s): Permanent
22. Cc fica ' vv�
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 Sigoa of C ed Well Con ctor Date
repair under#21 remarks section or on the back of Phis form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 13A NCAC 02C.0100 or I 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: 605 (ft)
For multiple wells list all depths if different(example-3Q 200'and 2®100) SUMITTAL INSTRUCTIONS
24s.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 UL)
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
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,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0.25 Method of test: Air 24c.For Water Supply Infection 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: 20 completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Ouahty Revised Jan 2013