GW1-2022-03534_Well Construction - GW1_20220324

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or muliple wells
14,WATERz2ANES xs
1.Well Contractor Information: _14
FROM TO DESCRIPTION
WILLIAM LAWSON 90 ft. 91 fti
Well Contractor Name
188 ft. 191 ft.
NCWC3491 A �15.OUTER CASING:( rru-lt%cased,wells)ORLINER(il applicab e
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 65 ft. 6.125 in- SDR 21 PVC plastic
Company Name ft. ft. in.
16 .INNER CASING O�2°TUBING tgeotherria'�hose loo ,�" `�'
2.Well Construction Permit#: W2022000038 5/6/1997COC FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction perimits(re County,State,Variance,eta ft, ft in,
3.Well Use: ft. ft. in.
7 SCREEN ]r `.... ,ir _ 'f
FROM� TO DIAMETER THICKNES SLOT S4 MATERIAL
Residential ft. M in
% ft. in
[I8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft
ft ft
ft. ft.
9SA�ND/GRAYELpPAC �if app ca
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
% ft ble
4. Date Well(s)Completed: 3/14/2022 Well ID# APPALACHIA COVE ft. ft.ft. ft.
5a. Well Location: a ua
l20 DRILLING I,OG(attach additional she_etsJLf nece sa ) >; =
List aft applicable well construction perimits(re County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ROBERT WILSON LOT 24 0 ft. 40 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 40% 65 ft. Gray Hard Granite SET
610 APPALACHIA CV MURPHY 28906 Lot 24 APPALACHIA COVE 65 ft 90 ft Gray Hard Granite
Physical Address,City,and Zip 90 ft. 91 ft. SMALL'FRACTURE 4 GFWR 9
Cherokee 452600806107000 91 ft. 188 % Gray Hard Granite
County Parcel Identification No.(PIN) 188 ft. 191 ft. LARGE''FRACTURE 75 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 191 ft. 205 ft. Gray Hard Granite ""j,%IATl pplt)f;E,91Q?j 1 f\ll-
(If well field,one lat/long is sufficient.)
35.174788 N -84.261022 W BIT SIZE 6.02"
i
6. Is(are)the well(s): Permanent I
22. C 'fi �
7. Is this a repair to an existing well: No 3/16/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Sigma of Ce red Well Contra for 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.0160 or 15A NCAC 02C.6200 Well Construction Standards and that a "
8. Number of wells constructed: 1 copy of lids record has been provided to the well owner.
For multiple irq'ection or non-water wells ONLY with the same construction,you can 23. Site diigriih or idditionil well dkbgi--
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 ifdiffereni(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of rasing: 60 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing use"+^ construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (iin>) 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: i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 75 Method of test: Air 24c.For Water Supply Iniection 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: 7 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013