GW1-2022-07471_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
.WA4T�R ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 315ft. 317 ft.
Well Contractor Name 327% 328 ft.
NCWC3491 A (`S.OUTER CA . G. fo t�ca ells U NER(rf app'cable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 & 85 fL 6.125 in- SDR21 PVC plastic
Company Name tt• ft 'in
6. °R GA ING O � geotherm_ a ose o0
2.Well Construction Permit#: W2021000143 W2021000142 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits Oe Counry,State, Variance,eta ft• ft in.
3.Well Use: IL ft in.
7. (sREEN
FROM TO DIAMETER TMCKNES SLOT SI# MATERIAL
Residential & ft. in.
& ft. in
�8.GRO
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
FL� VED 0 % 30 ft,
ft ft
9. . :A .if ap ca e
i -1'Rrd n's FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
IrttC?7f1 & ft
fL ft.
4. Date Well(s)Completed: 7/1/2022 Well EN
ft_ ft. i
5a. Well Location: 0. L G attach ad do a s ee 'necessary
List all applicable well construction pertinits(e County,State, Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RANDALL FLETCHER 0& 67 ft. Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 67% 85 ft. Gray Hard Granite SET CASING
2220 UPPER PEACHTREE RD MURPHY 28906 Lot 85& 315 & Gray Hard Granite
Physical Address,City,and Zip 315ft. 317 it LARGE FRACTURE 12 GPM
Cherokee 553200174706000 317 ft. 327 % Gray Hard Granite
County Parcel Identification No.(PIN) 327 fL 328 IL SMALL FRACTURE 3 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 328 fL 405 & Gray Hard Granite
(If well field,one lat/long is sufficient.) S
35.100247 N -83.910721 W BIT SIZE-5.85"
i
6. Is(are)the well(s): Permanent
22. Certificatio
7. Is this a repair to an existing well: No 7/6/2022
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature e n e C actor 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 1 SA NCAC 02C.0100 or I 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 injection 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: 405 (M)
For multiple wells list all depths if different(exmnple-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of rasing: 120 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing use"+"
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: hi 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): 15 Method of test: Air 24c.For Water Sunnly Iniection Wells: In addfron 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.
Form GW-1 North Carolina Denartmennt of Environment and Natural Resources - Division of Water Ouality Revised Jan 2013
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