GW1-2022-08942_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This font can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 278% 279 ft
Well Contractor Name 553 fL 554 fL
NCWC3491 A 115.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 fL 40 fL 6.125 i m SDR 21 PVC plastic
Company Name it. ft nu
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 0491 FROM TO DIAMETER THICKNES4 MATERIAL
List all applicable well construction pertmits(le County,State, Variance,eta fL ft in
3.Well Use: ft. ft m
17.SCREEN _
j yy�l� �1 f Q FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential R-`'� ' 9t�1 E "� ft. ft in.
S P I , 2022 118.GROUT fL ft m
�rti3S7�:xrn Unit FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
r[AVO 0G 0 fL 3 ft
3 ft 20 ft
fL ft
19.SAND/GRAVEL PACK(if applicable)FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
& ft
4. Date Well(s)Completed: 8/24/2022 Well ID# FONTANA TRACE fL ft
fL ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ze Caunty,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc)
FRANKLIN BAKER LOT 50 0 fL 22 ft Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 22& 40 ft Gray Hard Granite SET CASING
1868 FONTANA TRACE RD ALMOND 28702 Lot 40 R, 278 % Gray Hard Granite
Physical Address,City,and Zip 278 fL 279 fL SMALL FRACTURE 0.75 GPM
Swain 663200479159 279 fL 553 fL Gray&White Hard Granite
County Parcel Identification No.(PIN) 553 fl. 554 fL SMALL FRACTURE 0.25 GPM
5b. Latitude and Longitude degrees/mfnutes/seconds or decimal degrees: 554 ft. 645 ft Gray&White Hard Granite
(If well field,one lat/long is sufficient) (21.REMARKS
35.382473 N -83.589686 W
6. Is(are)the well(s): Permanent
22. Certi at-
If 7. Is this a repair to an existing well: No 9/10/2022
If this is a repair,fill out known well construction information and explain the nature of the Signature o ettifiedV Well Contracto a e
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 15A NCAC 02C.0200 Mell Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple i4ecdon or non-water wells ONLY with the same constnuction,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: 645 A)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 40 (ft)
24a.For All Wells: Submit this�form within 30 days of completion of well
Ifwater level 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
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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): 1 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: 30 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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