GW1-2022-01453_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4.WA2R ZC1�1yES y w
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 87 ft. 88 ft.
Well Contractor Name 158 ft 160 ft
NCWC3491A 1S �CIT_ERCASING(ldrmulh-cased wells)OR'f9I1(rfap hcabi) �_ .,
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 % 40 ft. 6.25 in. SDR 21 PVC plastic
Company Name ft. ft. in.
6 RCASINGO ,T -;(geo Banal ose loop) §�
2.Well Construction Permit#: W2021000607 2021000198 FROM.,., TO r T DIAMETER TIECKNESI MATERIAL
List all applicable well construction pertmits(e County,State, Variance,etc ft. % in,
3.Well Use: ft. ft. in.
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential gg .a ft. ft. in.
ft. ft. in.
z g01
FROM F TO MATERIAL F EMPLACEMENT METHOD&AMOUNT
,PN, L+ �ti,i,11• 0 ft. 3 fL Bentonite Pe
ft. ft.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
ft. ft.
4. Date Well(s)Completed: 11/8/2021 Well ID# HIGDON FARM PROP ft. ft.
5a. Well Location: 20 DRTLI3NGILt (atnch add(`t[onnl s ee i iffneessa' ty� �
List all applicable well construction pertmits(e County,State, Variance,eta t— T DESCRIPTION
n
FROM TO DESCRIPTION(color,hardness,sod/rock type,gain size,etc)
CYNTHIA&JAMES BATEMAN 0 ft. 22 & Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 22 ft. 40 ft. Gray Hard Granite SET CASING
3260 HEALEY FIELDS RD ANDREWS 28901 Lot 40 ft. 87 ft. Gray Hard Granite
Physical Address,City,and Zip 87 fL 88 ft. Gray Fractured Granite SMALL FRACTURE 1 GPM
Cherokee 554603038993000 88 ft. 158 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 158 ft. 160 & Gray Fractured Granite LARGE FRACTURE 20 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: [ 160% 205 f1. Gray Hard Grande
(If well field,one lat/long is sufficient.) 1KS� o
35.200773 N -83.885811 W BIT SIZE 5.91"
6. Is(are)the well(s): Permanent
22. Ce ti �WeIHIC...atfr�
7. Is this a repair to an existing well: Noy�(f' 1/10/2022
If this is a repair,fill out known well construction information and explain the nature of the Signature e [e
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 I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple iryection 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 di f"erent(example-3@ 200'and 2 @ 1009 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 (fL)
construction to the following:
If water level is above casing,use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (11.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addition 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,Undergronn Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Supply Infection Wells: In addition 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: 10 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dcoartment of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013