GW1-2022-07468_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mutiple wells
.WAT R ZO S
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 147 fL 148 ft.
Well Contractor Name 175 t1. 180 ft.
NCWC3491 A 5.OUTER CASING for ti-cis w s OR ER rf a 'cab e
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 75 fL 6.125 1"'• SDR21 PVC plastic
Company Name ft. ft. i in.
6. R CASI G O Ufl G(geo erma clo a oo )
2.Well Construction Permit#: W2022000012 W202200003 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction perhnits Cie Count};State, Variance,eta ft. fL in.
3.Well Use: ft. ft. in.
FROM TO DIAMETER TMCKNES SLOTSI# MATERIAL
Residential fl. ft. in.
E `Mf D ti.GRO T ft. in
FROM TO MATERIALPe EMPLACEMENT METHOD&AMOUNT
qiJr, 2Q22 0 fL20ft
ft. ft.
+ntt vn aao��'r�c �J fL fL
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
% ft.
4. Date Well(s)Completed: 6/28/2022 Well EM MAJESTIC MTN
fL fL
5a. Well Location: 20.D ING a ch ad opal s eats',necessary
List all applicable well construction pertmits he County,State, Variance,etc, FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
DON&DENISE BRISBINE LOT 46 0 ft_ 46 ft. Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 46 ft. 75 ft. Red Medium Slate
1600 MAJESTIC MTN TRL MURPHY 28906 Lot 75 ft. 147 ft. Gray Hard Granite
Physical Address,City,and Zip 147 ft. 148 ft. SMALL FRACTURE 6 GPM
Cherokee 456300098714000 148 ft. 175 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 175 ft. 180 ft. LARGE FRACTURE 34 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 180 ft. 205 fL Gray Hard Granite
(If well field,one lat/long is sufficient.) MA S
N W -5.97"
35.123169
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 6/29/2022
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified ell Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby cerh;fy that the well(s)wus(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 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 it jection 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: 205 (ft.)
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: 100 (ft.)
If water lavel is above casing,use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In a'ddtion 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): 40 Method of test: Air 24c.For Water Supply 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: 100 completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013