GW1-2022-00262_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.NYATFR ZONES._-
1.Well Contractor Information: - - — -
FROM TO DESCRIPTION
WILLIAM LAWSON 153 ft 154 fl. I i
Well Contractor Name 189 fL 191 fL
NCW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(yrf app)icable)-
NC Well Contractor Certification Number FROM TO DIAMETER THICIUMSS MATERLAL
CHEROKEE WELL DRILLING 0 B• 60 ft 6.125 I in SDR 21 PVC plastic
Company Name R nL
�^
16..INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000686 2021000381 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pertmits(te County,State,Irariance,etc. fL fL. ;'in,
3.Well Use: ft "in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential a; ""' IL ft. in.
;1— fL. fL in
° q 18.GROUT
FROM TO MATERIAL EMPLACEMENT NMTROD S:AMOUNT
c1'r`A ft. ft
ft fL
19.SAND/GRAVEL PACK(if applicable) RN
FROM TO MATERLALI EMPLACENMNT METHOD&AMOUNT
4. Date R'ell(s)Completed: 12/9/2022 Well ID# ft. ft.
tt. ft j
5a. Well Location:
20:DRILLING-I,OG;(attach additionalsheetsif necessurp)-------F•-�---�---
List all applicable well construction pertmits(fe County,Stag Kiriance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ROCCO BAUMSTARK Oft 38 ft. Brown Medium Slate
Facility/Owner Name Facility ID(ifapplicable) 38% 60 IL. Gray Hard Granite SET CASING
1600 COOK CREEK RD MURPHY 28906 Lot 60 ft. 153 ft. Gray Hard Granite
Physical Address,City,and zip 153 ft 154 % SMALL FRACTURE 5GPM
Cherokee 458500945160000 154 fL 189 M Gray Hard Granite
County Parcel Identification No.(PIN) 189 fL 191 fL I LARGE FRACTURE 15 GPM
5h. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 191 ft 1245 fL I Gray Hard Granite
(If well field,one lat/leng is sufficient) 21.RE
35.165403 N -84.056151 W BIT SIZE 6.09" !`
G. Is(are)the well(s): Permanent (�
22. Certify io
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 of the Signature of Certified Well Contra for Date
repair under If 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 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
S. Number of welts constructed: 1 copy of this record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same constriction,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: 245 (fL)
For multiple wells list all depths if dit Brent(example-3®200'and 2 @ 1009 SUUIITTAL INSTRUCTIONS
(ti) 24a For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 50
If seater level is abm•e casing,use"+" construction to the following:
Dnision of AI'ater Qu.tlity,Information Procession Unit,
11. Borehole diameter: 6 Cm.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 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 folioMng. I,
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 iN'Iafl Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the form to
the address(es)above,also submit one copy ofthis form within 30 days of
13b. Disinfection type: HTH Amount: 10 completion of well construction to the I o i ty health department ofthe county
where constricted
Form GlN-1 North Carolina Deartment of Environment and Natural Resources -Division of Water Ouaiitvi Revised Jan 2013
a