GW1-2022-06553_Well Construction - GW1_20220419

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 350 ft. 351 fL
Well Contractor Name ft ft
NCWC3491 A 15 L3UE2 GASTG(fomultec,sezl s1t 'rLrR�if ph41
NC Well Contractor Certification Number FROMM TO DIAMETER THICIu''3ESS �4ATERIAL
CHEROKEE WELL DRILLING 0 ft. 60ft 6.125 in. SDR21 I PVC plastic
Company Name ft ft 1n-
16
2.Well Construction Permit#: W2022000122 FROM TO DIAMETER TMCMNESS MATERIAL
List all applicable well construction pertmits(ie Countc,State,Plariance,etc. ft. fL in I
3.Well Use: __.__=-= =—'n - �_ ......._ ...,._...---___-.
?w Ste_ EMI a
FROM I TO I DLA 4ETER THICKNESS I SLOT SIZE INIATERIAL
Residential ft J ft. in I
ENED
FROM TO MATERIAL Jill1PLACEMERT METHOD g AIVVIOL'NT
APR 9 202Z ft ft Bentonite Pelletts SO Gravity
uAK 3
ft 20 fL �
FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 4/12/2022 Well ID# SOURWOOD RIDGE ft. ft.
ft. fL
5a. Well Location: r x
� 95dt1<[tDTIa.SSh �3
List all applicable well construction pertmits fie County.State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JACOB CHASTAIN TRACT 15 Oft. 28 ft. Tan Medium Slate
Facility/OKmer Name Facility ID(if applicable) 28 ft. 160 & Gray Hard_ Granite SET CASING
VICTORY LN MURPHY 28906 Lot
60 ft 350 ft. Gray Hard Granite
Physical Address,City,and Zip 350 ft. 351 ft. SMALL FRACTURE 0.125 GPM
Cherokee 458300198916000 351 ft. 605 ft. Gray Hard Granite
County Parcel Identification No.(PIN) M ft.
5b. Latitude and Longitude degrees/ntinutes/seconds or decimal degrees: ft ft
(If well field,one laVlong is sufficient.)
35.127223 N -84.079371 W I BIT SIZE-5.98"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing wen: No � � 4/13/2022
If this is a repair,fill out known well contraction information and explain the nature of the Signature of Certifi ell Cnnlractor Date
repair under 9 21 remarks section or on the back oftltis form. at,signing this form,I hereby✓cerrifi•that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
8 Ntunber of wells contracted: 1 copy of this record has been prmided to the uvil owner._.
For multiple injection or non-water wells OW Y 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: 605 (fL)
For multiple wells list all depths ifdi ferent(example-3@ 200'and 2 @ 100) SUI•IITTAL INSTRUCTIONS
10.Static water level below top of casing: 200 (ft) 24a.For All Wells: Submit this fort 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 On.) 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 for is within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: i Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service,Center,Raleigh,NC 27699-1636
13a Yield(gpm): 0.125 Method of test: Air 24c-For Water SupRly Infection'Webs: 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: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-2 North Carolina Department of Environment and Natural Resources -Division of Water Qualitv Revised Jan 1-013