GW1-2022-08984_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAMLAWSON 272M 273 ft
Well Contractor Name 342 ft 343 ft i
NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNES MA't FRr L
CHEROKEE WELL DRILLING 0 ft. 47 ft 6.125 j i'r SDR21 PVC plastic
Company Name ft' ft yr
16.INNER CASING OR TUBING(geothermal closed
2.Well Construction Permit#: W2022000128 2022000127 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(le Count};State,Variance,eta ft. ft in,
3.Well Use: ft ft in.
17.'SCREEN
a g FROM TO DIAMETER UUCKNES SLOTS MATERIAL
Residential �( ��' � ft ft in
ft. ft in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 20 ft
v'.'eti+r .vL tit. ft
ft. ft.
19.SAND/GRAVEL PACK(rfapplic5ble)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. %
ft ft
4. Date Well(s)Completed: 7/27/2022 Well EM
ft. ft.
5a. Well Location: �0..DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(:e County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
CHARLES&SANDY LEDFORD 0& 17 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 17ft. 47 ft Gray Hard Granite SET CASING
25 ODELL LOOP MURPHY 28906 Lot 47 ft. 272 ft. Gray Hard Granite
Physical Address,City,and Zip 272 ft 273 % SMALL FRACTURE 0.25 GPM
Cherokee 459500487608000 273 ft. 342 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 342 ft. 343 % SMALL FRACTURE 0.75 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 343% 605 ft Gray Hard Granite
(If well field,one latilong is sufficient) 21.REMARKS
35.18005 N -84.040075 W BIT SIZE-5.97" I
6. Is(are)the well(s): Permanent
22. Certifica'
7. Is this a repair to an existing well: No 7/28/2022
If this is a repair,•fdl out known well construction information and explain the nature ofthe Signature of Cc
ed Well Contractor ' Date
repair under#21 remarks section or on the back of this form. By signing this fora,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 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: 605 (ft-)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 1009 SUMTTTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 200 (ft-)
construction to the following:
If water Ievel 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 Iniection 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 276994636
13a. Yield(gpm): 1 Method of test: Air 24c.For Water Supply Iniectiori 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. Jf
Form GW-1 North Carolina De m armment of Environment and Natural Resources -Division of Water., Revised Jan 2013