GW1-2022-09636_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: i4,_WATER ZONES - - __ _
FROM TO DESCRIPTION
WILLIAM LAWSON 170 fL 171 ft.
Well Contractor Name 330 ft. 335 ft-
i
NCWC3491 A 15.015TER CASING(for multi-cased wells)OR LINER(fapplicable)
NC Well Contractor Certification Number FROM TO DIAMETERi THICKNES1 MATERIAL
CHEROKEE WELL DRILLING 0 ft. 76 ft. 6.125 i in SDR21 PVC plastic
Company Name ft. ft. in.
116.INNER CASING OR TUBING(geothermal closed loop);
2.Well Construction Permit#: W2022000605 12/5/06 FROM TO DIAMETER THICKNE&I MATERIAL
List all applicable well construction pertm is(le County,State, Variance,eta it. M in
3.Well Use: it. ft. 14n.
17.SCREEN_::;,_
FROM TO DIAMETER THICKNES SLOTS4 MATERIAL
Residential ft. ft in
ft. It. in.
18.GROUT°
,D M V ED FRO tt To ft MATERIAL EMPLACEMENT METHOD&AMOUNT
rr
O`,1 2 1 2022 & It. I
..--- -
ft. ft. -
19.SAND/GRAVEL,PACK(if applicable):
�W j{�faCY�3 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
it. ft.
4. Date Well(s)Completed: 10/18/2022 Well ID# ft. ft.
ft. %
5a. Well Location: i20.,DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(le County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JEFF&KATE THILO 0 ft 60 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 60 it. .76. ft. Gray.Hard;Granite,SET CASINO-
142 TILSON RD MURPHY 28906 Lot 76 L--,17&. ,M.. Gray'Hard;Granite
Physical Address,City,and Zip 170M 171: ft. SMALLFRACTURE 0.5 GPM
Cherokee ` ' 453002978113000 171 ft 330 ft.` Gray Hard'.Granite'
County; Parcel Identification No.(PIN) 330 ft. 335 fL Fractured WATER ZONE 100 GPM
5b. Latitude;and Longitude degrees/minutes/seconds or decimal degrees: 335 fL.345. m Gray Hard Granite
(If well field,.one latRong is sufficient.) �21.REMARKS
35.03081 N -84.21379 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. C7of
7. Is this a repair to an existing well: No
If this is a repair,fill out known well construction information and explain the nature ofthe Signatu C ntr r Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby cerh;fy' thalt the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple iryection 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: 345 (fL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If water Ievel 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 iitethod: ROtary air" _+' 24b.For Infection Wells: In addtioir to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy ofthis form withm 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):;,_ 100�-; 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
13ba Disinfection type• HTH Amount: 100 completion of well construction to the bounty health department of the county
where constructed.' I!
Form GW-1 North Carolina Department of Environment and Natural Resci rces -Division of Water Quality Revised Jan 2013