GW1-2022-07644_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells q
LVI R¢ E
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 263 ft. 264 ft.
Well Contractor Name 362 ft 363 ft
NCWC3491 A 5�0UT R CA for Leased Q (if a plic .
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 60 fL 6.125 in. SDR21 PVC plastic
Company Name ft. ft. in.
16. :R C�1SI. _ UBI: geo erma c ose o0
2.Well Construction Permit#: W2022000509 4/29/87 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction perimits he County,State, Variance,etc. It. ft. in,
3.Well Use: ft. ft. �DW,=�ER �THICKNES
FROM TO SLOT�SIZMA�
Residential ft. ft. in
EI S.c ft., ft.
rXEC
AU�� FROM
0 ft 20 ft T MATERIAL EMPLACEMENT METHOD&AMOUNT
2`ZZ
ft ft.
dOI1 R;'a��u� ft. ft.
.1qQJt3
DJG - YE A jjepp'cab e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. fL
ft. ft.
4. Date Well(s)Completed: 8/12/2022 Well Ili
5a. Well Location:
20. LING OG a c dditio,a s ee '3necessa .
List all applicable well construction pertmits fle County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc)
BRENT HEENAN 0 M 40 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 40 it, 60 ft. Gray Hard Granite SET CASING
40 STONE DR MURPHY 28906 Lot 60 ft. 263 ft. Gray Hard Granite
Physical Address,City,and Zip 263 It. 264 ft. SMALL FRACTURE 2.5 GPM
Cherokee 445900595743000 264 It. 362 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 362 It. 363 % SMALL FRACTURE 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 363 fL 405 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.)35.013225 N 84.160835 W Tmrn"�
6. Is(are)the well(s): Permanent
22. Certific!' ;W
7. Is this a repair to an existing well: No 8/12/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Ce �Contlracltor
repair under under#21 remarks section or on the back of this form. By mgmng this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A 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 hyection 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 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 90 (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: 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,JUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 3 Method of test: Air 24c.For Water Supply Iniectioi 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: 15 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013
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