GW1-2022-06023_Well Construction - GW1_20220621

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER 2ANES
FROM TO DESCRIPTION
WILLIAM LAWSON 201 ft. 204 ft.
Well Contractor Name tt. ft.
NCWC3491 A �15.OUTER CASIiVG(for multi=cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TWCKNESJ MATERIAL
CHEROKEE WELL DRILLING 0 ft. 42 M 6.25 im. .188 Steel-black
Company Name & ft.
`16.INNER CASING ORTUBIIVG(geothermal closed loop)
2.Well Construction Permit#: W2022000034 FROM TO DIAMETER MCKNESI MATERIAL
List all applicable well construction perimits Cie County,State,Variance,eta ft. ft, in,
3.Well Use: ft. ft. in.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential flL ft. in.
It. ft. in.
FROM TO MATER XL EMPLACEMENT METHOD&AMOUNT
0 & 20 ft
tit. ft.
% fL
!LS RAND/GRAVEL PACK(if apl icable) J
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
% ft.
4. Date Well(s)Completed: 6/2/2022 .Well ID# It. ft.
flu. tl
5a. Well Location:
i20.DRILLING I OG(attach additional sheets if irecessary)
List all applicable well construction pertmits(e County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil"ck type,grain size,etc)
BILL MCNABB 0 it. 15 ft. Red Medium Clay
Facility/Owner Name FacilityID(ifapplicable) 15,i1... .42. _ft. Gray Hard Granite SET CASING•
3181 LOWER BEAR PAW RD MURPHY 28906 Lot 42 ft 201 f1 Gray Hard Granite
Physical Addres.7. y,and Zip- 201 fL 204 . ,ft.- LARGE FRA : .- FEAJb r
r -
Cherokee 454300866104000 204% 225 ft. .Gray Hard Granite"y- _
County Parcel Identification No.(PIN) ft. tl. J U N 2 1 2022
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: fL M
(If well field,one lat/loug is sufficient.)
35.11374 N -84.19012 W BIT SIZE 5.97"
6. Is(are)the well(s): Permanent
22. Ce 'ficati
7. Is this a repair to an existing well: No
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Sign -_ er[ified Well Con c[or 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 15ANCAC 02C.0100 or 15ANCAC 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.
For multiple infection 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: 225 (ft-)
For multiple wells Est all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS'
10.Static water level below top of casing: 20 (ft.)
24a.For All Wells: Submit this form within 30 days of completion of well
_
Ifwater level is.above casin&use'+' construction to the.following: . . -
Division of Water Quality,Information Procession Unit,
11. Borehole.diameter: 6 (jn.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to'sending the form to the address in 24a
(ie,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,Undergrouin Injection Control Program;
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 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 ofthis 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.
hForm GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013