GW1-2022-09470_Well Construction - GW1_20221017

I
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 152ft. 154 ft.
Well Contractor Name 367 ft 368 ft
NCWC3491 A 115.OUTER CASING'(for multi-cured wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TIRCKNESI MATERIAL
CHEROKEE WELL DRILLING 0 ft 100 ft 6.125 j,in SDR 21 PVC plastic
Company Name M ft. 1 m.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2020000014 W2020000013 FROM TO DIAMETER TfUCKNES4 MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc. ft, ft in.
3.Well Use: M ft in.
17.SCREEN '
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential it. fL in.
M ft in.
18.'GROUT
y{ p, ,a t� n =m i �i Y 2•= FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 fL 20 ft
0 C T 1 72022
-w Unit ft. ft
J19.SAND/GRAVEL-PACK(ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
M ft
4. Date Well(s)Completed: 10/13/2022 Well ID# ft.
fL M
5a.• Well Location: 20`DRILLING LOG(attach"additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,eta FROM TO'-'.': ':`':'DESCRIPTION(color,hardness,:soil/rock type,:grain size,etc)
.BRANDON..WATKINS• 0 ft "84`> 'ft '=Red Medium`Sla#e"
Facility/Owner Name Facility lD(if applicable) '84ftL -10T"ft.'''G"ray Hard Granite SET CASING
885 HWY 294 MURPHY 2890ti'Lot
r : 100 fL-152--_tt._--Gray Hard Granite
Physical Address,City,and Zip " '°152 tt 154 ,.fit • ' SMALL FRACTURE 4 GPM'
Cherokee 455100909111000 154% 367.'-,.fL,'.:•Gray Hard;Granife'."
County' Parcel IdentificationNo.(PIN) .367•ft:.368 ft;. SMALL FRACTURE 2 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 368%,405" fL Gray Hard,Granite
(If well field,one latllong is sufficient.) i.REMARKS_ -
35.042415 N -84.147739 W BIT SIZE"5.57"
6. Is(are)the well(s): Permanent
22. Certificati i
I.
7. Is this a repair to an existing well: No 10/13/2022
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature of Cc ntractor f/t� tt'•'
repair under#21 remarks section or on the back of this form. By si8ntn8 this orm,I hereby certify that the weil(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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 fora 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 ifdifferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS 1
I,
24a.For All-Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft-) I.
construction to the following: ;
If water level is above casing,use'+^ Division of Water-QualitY:Information Procession Unit,
„
11. llorehole diameter: 6 (in.) `.'1619 MAService-Center,Raleigh,NC-27699-1617
12. Well construction method: Rota air 24b:For Infection Wells:. •.Li addtion to sending the foim.to the.address in 24a . .
rY
(ire.auger';rotary,`cable*direc{piis}i etc.) above;'also submit a copy'of this fonn within 30 days of completion of well -- .
,I. - �,.••�.
construotion to the following
Ti OR,WATER SUPPLY WELLS ONLY: Division'of Watei Qual ty,'Undergroun Injection Control Program,
- . 1636 Mail Service Center,Raleigh"NC 27699-1616
13a. Yield(gpm): 6 Method of test: Air 24c.For Water'Supply Inlectionffellsr ' hi addtion'to'sendingthe form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 20 completion of well construction to the county health department of the county
where constructed. FC
Form GW-I North Carolina Deoartnient of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013