GW1-2022-03961_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: -- — -
FROM TO DESCRIPTION
WILLIAM LAWSON 152 tit. 162 ft
Well Contractor Name 190 ft. 193 ft.
NCWC3491A �15.Oi1TER CASING(for,multi cased4effi OR,I IPIER(ifapphcab e� s
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 ft. 100 ft- 6.125 m- SDR21 PVC.plastic
Company Name ft. ft. in.
t16 I1�1V_ER GA`SINGOR��UBIIVG(geotLermal,closed�'loop);� -
2.Well Construction Permit#: W2021000764 2021000541 FROM TO J DIAMETER ~^THICKNES MATERIAL
List all applicable well construction pertmits(te County,State,Variance,etc it• ft in.
3.Well Use: fL ft. in.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft. ft. in.
ft. ft. in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 3 ft
ft 20 ft
ft. ft.
19 SA`ND/GRAVEL'PACK{(d pph�b'lb��' y;: _ _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
ft. ft
4. Date Well(s)Completed: 2/11/2022 Well ID# EAGLES LANDING
ft. ft.
5a. Well Location: 0 DRILLING LOGttach adt�ilxonal sh etsit neces ary) ' _
List all applicable well construction pertmits(re County,State, Variance,etc _ �
FROOMM TO DESCRIPTION(color,hardnesrdnds s,sod/rock type,gram size-,etc)
-KEN RINGEL LOT 22 0 ft. 72 ft Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 72 fL 100 ft Gray Hard Granite SET CASING
65 CRESTED DR MURPHY 28906 Lot 22 EAGLES LANDING 100 ft. 152 ft. Gray Hard Granite
Physical Address,City,andZip 1.52 fL 1.62 ft. LARGE.FRACTURE 20.GP-M
Cherokee 456100679811000 162 fL 190 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 190 fL 193 ft. LARGE FRACTURE 10 GPM
Sb. Latitude and Longitude degrees/minntes/seconds or decimal degrees:
193 ft. 205 ft. Gram atl raft ���
U. REMARKS'
(If well field,one tat/long is sufficient.)
35.064509 N -84.125804 W BIT SIZE-6.03" - h A r
6. Is(are)the well(s): Permanent ,•
22. CeWecaflon: lt+r; �1±
7. Is this a repair to an existing well: No ! 'i eg ' ��f JlrGvV���1 2/14/2022
I,fthis is a repair,fill out known well construction information and explain the nature ofthe Sigma Contrattor 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 I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple irg'ection or non-water welts ONLY with the same construction,.you can 23. Site diageaiii of 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 (M)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 (ft)
construction to the following:
If water level is above casing,use"+"
Division of Water Quality,Infonration Procession Unit,
11. Borehole diameter.: 6 (in.) 1.617 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): 30 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: 12 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoartment of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013