GW1-2022-09637_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells 1
1.Well Contractor Information: 14.WATER ZONES- - `- '-
FROM TO DESCRIPTION
WILLIAM LAWSON 172 fL 174 ft.
Well Contractor Name 278 it. 280 ft f
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 ft, 50 ft 6.125 fin SDR21 PVC plastic
Company Name fL ft lin
116.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000398 2022000397 FROM TO DIAMETER 1-MCKNES4 MATERIAL
List all applicable well construction pertmits rie County State,Variance,eta ft M in.
3.Well Use: fL ft in.
17.SCREEN.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential fL ft in.
fL ft in.
•i 18.GROUT
C 'iV FROM TO MATERIAL EMPLACEMENTIv1ETH01)&AMOUNP
0 fL 20 ft
flr� 1 �022 M ft
Ufa ft fL
,�OlpCt L SAND/GRAVEL-PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft
4. Date Well(s)Completed: 10/11/2022 Well ID# WOLF MOUNTAIN EST ft
FL ft.
5a. Well Location:
�0.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits die County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ADAM SKELTON 17-19 0 fL 27 ft Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 27 ft. 50 ft Gray Hard Granite.SET CASING
196 SCENIC VISTA DR MURPHY 28906 Lot 17,18 WOLF MTN ESTATES-SECTION 2 50 ft 172 fL Gray Hard Granite
Physical Address,City,and Zip 172 ft 174 ft SMALL FRACTURE 4 GPM
Cherokee 451000673170000 174% 278 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 278 ft. 280 ft. SMALL FRACTURE 4 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 280It 305 it. Gray Hard Granite
(If well field,one lat/loig is sufficient) 21.REMARKS
35.027431 N -84.292397 W BITE SIZE-5.61"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No �� 10/12/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Cued W Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,l hereby cerhfy that the well(s)was(were)constructed in accordance
with 1SANCAC 02C.0100 or 15ANCAC 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 it jection 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: 305 (ft)
For multiple wells fist all depths if&fferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS j
10.Static water level below top of casing: 60 (ft) 24a.For All Wells: Submit this,form within 30 days of completion of well
construction to the following:
If water level is above casing,use'+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1'
12. Well construction method: Rotary air 24b.For Infection Wells: In addtioh to sending the form to the address in 24a
(ie.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): 8 Method of test: Ar 24c.For Water Snimly Infection W
i ebs: 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 tide 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