GW1-2022-03072_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
i4 WTR7AlVS
I.Well Contractor Information: 2.
,FROM x TO M DESCRIPTION
WILLIAM LAWSON 260 fL ( 261 fL
Well Contractor Name
310 R_ 311 ft.
NCWC3491A 150TEKCrl;i14G{fornuItrcedvicells;ORR(if __
INC Well Contractor Certification Number FROM TO _ DLAIviETER .z .- TIRCKNESS MATERIAL
CHEROKEE WELL DRILLING 0 <L 100il- 6.125 rn SDR 21 PVC plastic
Company Name ft R i
6:Ti���'.R_rC'ASIL1ICs UR'�T`U-$I�frCbtIt � �CIO �(Wjl���,i ,'
2.Well Construction Permit#: W2021000612 2021000359 FROM TO w DIAN4ETER THICkNESS MATERIAL
List all applicable wellconstruction pertrr;;(teCounts:Staff Y manm etc. R- ' gl, in,
3.Well Use: ft. in FROM TO DLA,fETER THICK-NIESS i SLOT SIZE 1N4ATERIAL
Residential fit. ' fL
fit ft. in.
1
T' FROM TO MATERIAL ENIPI ACEMENT METHOD R AN40'UNT
q'dR (�7 0f. ft.
f il' Bentonite sluur� 150 Pum ramie I
DOW= l ?021 f f
r
^. �`� 4 19 SA�t-D/GI >��A[�Z�€a'pSzca6le}`�
L.' I FROM G.TO MATERVAL &%VLACEMENT METHOD& sN40LNI
i I I & tit. I
4. Date Well(s)Completed: !1/24/2021 Well ID#
Sa. Weil Location: 0 I}RII LINts lO(u((ztfach addomeets i£ � k
List all applicable w•elI cons-nuciion pertmits tie Counh,,State,b arlanee�eta FROM TO DESCRIPTION(color,hardness,solikock type,grain size,etc)
BARRY KOONTZ Oft. 72 1f Tan Medium Slate
Facility?OwnerName Facility ID(ifapplicable) 72ft 100 ft. Gray Hard Granite SET CASING
1505 JOHNSOWLLE RD MURPHY 28906 Lot 100 ff 260 fL Gray Hard Granite
PhysicdAddress,City,and Zip 2608. 1261 fL . Gray Fractured Granite SMALL FRACTURE 3 GPM
Cherokee 442900573851000 261 It 310 fL Gray Hard Granite
County Parcel Identitication No.(PNi 310% 1311 ft. Gray Fractured Granite SMALL FRACTURE 1 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 311 ft. 405 8 Gray Hard Granite k
(If well field,one latlong is sufficient.) 1 RE1<4ARii .r ra „`t, y
35.004284 N -84.259938 W BIT SIZE 5.71"
I
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 12113M21
Ifthis is a repair,fill out known well construction information and explain the nature of the Signature of .ertified ivell Contractor Date
repair under#21 remarks section or on the bad(ofthis form. By signing tins form,I hereby cer 6,that the well(s)was(were)constructed in accordance
with 15A ACAC 02C.0100 or 15-4 NC4C 02C.0200 Well Construction Standards and that a
$. dumber of wells constructed 1 copy of this record has been provided to the well owner.
For multiple it jecton or non-water Hells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one farm You may use the back ofthis page to provide additional well site details or well
constriction details. You may also attach additional pages if necessary
9.Total well depth below land surface: 405 (It.)
For multiple wells list all depths ifdlfferent(example-3@ 200'and 2 @ 100) SUAIITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (tit.)
construction to the following,.-
Ifwater level is above casiRk use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (irr.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In attrition 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 FVATER SUPPLY AVELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. I Jeld(gpm): 4 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: 15
completion of well construction to the county health department ofthe coin
where constructed-
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan 2013