GW1-2022-06556_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
eft—,TV R 7ANES 31 vt' Y ;r
1.Well Contractor Information: -
FROM TO DESCRIPTION
WILLIAM LAWSON 315 ft. 316 ft.
Well Contractor Name 517 fL 518 &
NCWC3491 A 5 OUP ERCASING(for t► se� s)O �IINER(it;app cable
NC Well Contractor Certification Number FROM TO 1 DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 85 tt- 6.125 in. SDR 21 PVC plastic
Company Name & ft. in.
6 I NEMCASIr�G;OR TT�UB G'(geotherma c ose sloop
2.Well Construction Permit#: W2022000111 W2022000045 FROM TO DIAMETER THICKNES4 MATERIAL
List all applicable well construction perhnits(re County,State,Variance,eta ft, it, in
3.Well Use: fL ft. In.
INN
FROM n TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft. in.
ft. M in.
�(P Tz-yvl/d;r. 01 ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
APR T, 0 ft. 20
ft. ft.
�y n fL ft.
Cat
LACKFifaa Lca e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
ft. ft.
4. Date Well(s)Completed: 4/14/2022 Well lD# CARL DICKEY SUB
it ft
Sa. Well Location: Ft2DRILISING�aadd�r'¢tfonal�ishee �' necessa .
List all applicable well construction perimits(re County,State, Variance,etc FROM TO DESCRIPTION(color,hardness,soiYrock type,grain size,etc)
MIKE BRADBERRY LOTS 45/46 0 ft. 62 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 62 fL 85 fL Gray Hard Granite SET CASING
10 COATS DR MURPHY 28906 Lot 85 ft. 315 & Gray Hard Granite
Physical Address,City,and Zip 315 fL 316 ft. SMALL FRACTURE 1 GPM
Cherokee 456004539428000 316 ft. 517 fL Gray Hard Granite
County Parcel Identification No.(PIN) 517 ft. 518 ft. SMALL FRACTURE 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 518 ft. 605 & Gray Hard Granite
(If well field,one lat/long is sufficient.) 1 RCMARtCS>._ � v ti M1�3v _tea r �g
35.024478 N -84.127622 W BIT SIZE 5.97"
6. Is(are)the well(s): Permanent
2. Certification:
7. Is this a repair to an existing well: No 4/28/2022
If this is a repair,fill out known well construction information and erplain the native ofthe Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,l hereby certify that the we11(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
_A.._Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple iryecuon 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: 605 (fL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (fL)
If water level is above casing,use"+" construction to the following
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 0-) 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 3 Method of test: Air 24c.For Water Sunnly 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: 25 completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Deoartrnent of Environment and Natural Resources - Division of Water Oualitv Revised Ian 2013