GW1-2022-09266_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 90& 95 fL
Well Contractor Name 155 ft 157 ft
NCWC3491A 77777; 77=
pR..- lica e _NC Well Contractor Certification Number THICKNES MATERIALCHEROKEE WELL DRILLING DR 21 PVC plasticCompany Name
�6:�-_ NER Cif G--R UB G?�(g"eotlierrria`elosed`oo -
2.Well Construction Permit#: 22022000549 2022000533 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits lie County.State, Variance,eta fL ft.
3.Well Use: ft' fL in.
��s�_, 'EIS•. . . .
FROM �TO j DIAMETER THICKNES SLOTS MATERIAL,
Residential fL fL in.
fL ft. in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft
2022 fL ft.
fL fL
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
fL ft.
4. Date Well(s)Completed: 9/28/2022 Well ID# HOLLY POINT @ NOTT
ft. ft. i
Sa. Well Location:
� - � G OG(a _ a ditionr.'s eetstff=n ary,� -
List all applicable well construction perbnits fie County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
BOBBY TURNER LOT 36 0 ft. 49 ft. Red Medium Clay
Facility/Owner Name Facility ID(if applicable) 49 ft. 70 fL Gray Hard Granite SET CASING
HOLLY POINT DR MURPHY 28906 Lot 36 70 ft. 90 IL Gray Hard-Granite
Physical Address,City,and Zip 90 ft. 95 fL Gray Fractured Granite WATER ZONE 5 GPM
Cherokee 446900293944000 95 fL 155 fL Gray Hard Granite
County Parcel Identification No.(PIN) 155 fL 157 ft. Gray Fractured Granite WATER ZONE 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 157 fL 205 fL Gray Hard,Granite
(If well field,one lat/long is sufficient.) _-
35.014508 N -84.138114 W BIT SIZE 5.62"
6. Is(are)the well(s): Permanent
22. Certifi 'on•
7. Is this a repair to an existing well: No 9/28/2022
If this is a repair,fill out known well construction information and explain the nature of the Signature of a eel Well Contracto Da
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 1 SA NCAC 02C.6200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been pravided 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: 205 (ft.)
For multiple wells list all depths if& erent(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 0L)
If water level is above casing,use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m.) 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): 10 Method of test: Air 24c.For Water Supply Iniection 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: 10 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoartrnent of Fnvirotmtent and Natural Resources - Division of Water Ouahty Revised Jan 2013