GW1-2021-02459_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD For hitetnal Use ONLY:
This form can be used for single or mutiple wells
t4 WATERfZO1VE5 = � � fi ,.,,
1.Well Contractor Information:
FROM TO _ DESCRIPTION
WILLIAM LAWSON 221 ft. 222 ft.
Well Contractor Name ft. fL
NCWC3491 A 5 OUTER CASING('f rmuitt asedT7e t10RLINER ifs pest g
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 " 48'" 6.125 SDR 21 PVO plastic
Company Name it ft. in.
6 INNER`CASINGORT�UBING`(geo ermalgclose,Iloojt) ,
o WeLlC,,..".,.hen na._ tff: ue 2021-1t:nnrv5 __.............. ........._...
. ..•,..—....•.,-•.••.••,..••••..»_... rtc�tvt tv r>tEuvt>rtrrc tru�;tuvra tvttitrtctwt,
List all applicable well construction perinuts(re County,State,Variance,etc ft• ft. in.
3.Well Use: fL ft. in.
Y h z�..->ss�Yv2T,'- �" Y - .fit �-`•--•;
17 SCREENr �
FROM TO DIAMETER THICKNES SLO�MATERIAL
Residential i' ft. ft in.
o fL ft. in.
f�
(.®�1 � ''t FROM TO MATERIAL EMPLACEMENT METHOD 8c AMOUNT
P�C t��e� 0 A.ft. 20 ft.
nJtlfl�p 5e J�0 ft. fL
VV4J 19SA1�TDlGRAVELAts (rfap hcabe}.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 7/22/2021 Well IM ft. ft.
ft. ft.
5a. Well Location: 20 D`RII.LIIGLOGttae�addttionallitfn 'ecessary)e �E
List allapnlicabiewellconstructionnertmitsfieCountvState.Variance.eta
CHARLES GREENWALD 0 ft. 26 it. Brown Dirty
Facility/Owner Name Facility ID(if applicable) 26 fL 48 fL Gray Hard Granite SET 46 CASING
154 HOLLY BERRY DR MURPHY 28906 Lot 48 fL 221 ft. Gray Hard Granite
Physical Address,City,and zip 221 ft. 222 ft. Fractured LARGE FISSURE 15 GPM
Cherokee 448901177142000 222 ft. 265 fL Gray Hard Granite
County Parcel Identification No.(PIN) fL ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient) 21 REMARKS � J` £ wy , j.'
35.010605 N -84.074894 W BIT SIZE 6.05"
6. Is(are)the well(s): Permanent
22. CertiWo7. Is this a repair to an existing well: NOifiras is a repair jiii oils known veil rwruiruciion informaiion row nrpuan lie naive of the 6ignauuentract r hate
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)wns(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.
Far multiple nyection or non-water wells ONLY with the same construction,you.can 23. 9Rc diaglinit ur$LL{ittttrnaa w 811 LLCtn-H5:
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: 265 (fL)
ror rnuitipie weiis itst ati deprits if arperem(example-3Cw 2u0:and 2 @ 1 u0) SL"��rTT,:I INc rurrr�a rn vc
10.Static water level below top of casing: 20 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
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 ofthis form within 30 days of completion of well
construction to the followings:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 15 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: 10 completion of well construction to the county health department ofthe county
where constructed.
Form GW-I North Carolina Deoarunent of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013