GW1-2022-09772_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14 WATER ZONES T
FROM TO DESCRIPTION
WILLIAM LAWSON 95 ft. 96 ft.
Well Contractor Name 355 fL 358 ft
i
NCWC3491 A 15.OUTER CASING(for multi--lased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 30 ft- 6.125 1. SDR21 PVC plastic
Company Name fi' ft in. _
116.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000548 10/9/810 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits ft County,State,Variance,eta fL ft in.
3.Well Use: ft ft 1r.
17.SCREEN
FROM TO DIAMETER URCKNES SLOTS MATERIAL
Residential ft. ft in
tt ft in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 R- 20 ft
e`Ge A ft. ft.
ft. fL
OCT 2 7 2Q22
t19.-SAND/GRAVEL-PACK(if applicable) -_--•
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
II►`'u;T�:t��'r::� v:� Unsi ft. ft
(j� iQ1 E°i ft. ft
4. Date Well(s)Completed: 10/17/2022 Well ID#
it. ft
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) _
List all applicable well construction perimits(le Coun)4 State,Variance,eta FROM TO DESCRIPTION.(color,hardness,soil/rock type,grain size,etc)
JEAN&MARTIN HAMBY 0 fL 9 ft Brown Medium Dirt
Facility/Owner Name Facility ID(if applicable) 9 fL 30• ft. Dark Gray.Hard Granite SET CASING
2W HIWASSEE DAM ACC.RD MURPHY 28906 Lot 30 ft 95 ft. Dark Gray Hard Granite
Physical Address,City,and Zip 95 ft. 96 ft. SMALL FRACTURE 3 GPM
Cherokee 454400620843000 96 ft"355 fL Gray Hard Granite
County Parcel Identification No.(PIN) 355ft. 358 _-ft..._. LARGE FRACTURE 171GPM "
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 358 M 385 fL. Gray Hard Granite,
(If well field,one lat/long is sufficient) ?2 REMARKS
35.129908 N -84.19965 W BIT SIZE-6.02"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 000-- 10/18/2022
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified WYontl4raclor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 rYell Construction Standards and that a
- 8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple i4ection 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: 385 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 20 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater 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
12. Well construction method: Rotary 81r 24b.For Injection 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 27699-1636.
13a. Yield(gpm): 20 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: 100 completion of well construction to the 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