GW1-2022-00280_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD
This Use ONLY:
This form can be used for single or mutiple wells
14 W�TERZCNES:
1.Well Contractor Information: _
FROM _ TO DESCRIPTION`w
WILLIAM LAWSON 268ft. 269 fit.
Well Contractor Name 590 ft. 595 ft.
NCWC3491A 15 O'f_TER'CASING(focniiilticasetl_e_ILs)ORLIIYER(ifapp7tcaLue}
NC Well Contractor Certification Number FROS4 TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 30 ft• 6.125 rr' SDR21 PVC plastic
Company Name ft: ft. UL
16.13 iNER CASING®R TUBI\TG{geatnei nW cPosed loop) y
2.Well Construction Permit#: 120622-P FROM TO DIAMtETER THICKNESS MATERIAL
List all applicable well construction pertmrits(ie County;State,i'ariarce,etc & It. in.
3.Well Use: ft ft. in
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential & fL in
ft ft. m
FROM TO MATERIAL_ _ EMPLACE MW METHOD S.AMOUNT
2 2 2022 o ft. 20 ft-
ft. ft
1n;0r H;a UN" ft. ft
v�PIQi OG 19 SAuNDIGRAVEL PACK ff a cable -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft:
=4. Date Well(s)Completed: 12/21/2022 Wen ID# ft. ft.
ft. ft.
5a. Well Location: 20;i}ItILL�G-I OG{attach adilitsonat sleets if neccssarv}
List all applicable well construction:pertmits(ie County,State,Variance,etc FROM TO DESCRIPTION(color,hardness;soill—k-type,grain size,`etc)
MARILYNN HAMMOND 0 ft. 5 ft. Brown Medium Slate
Facility/OwnerNatne Facility ID(if applicable) 5fL 30 fL Gray Hard Granite SET CASING'
1129 DEWEESE RD TOPTON 28781 Lot 30 fL 268 & Gray Hard Granite
Physical Address,,City,and Zip 268ft. 269 ft. SMALL FRACTURE0.75'GPM '
Macon 6528952297 269 fL 590 it Gray Hard Granite
County Parcel Identification No.(PIN) 590% 595 fL FRACTURED ZONE 24.25 GPM
5b. Latitude and Longitude degrees/ndnutes/seconds or decimal degrees: 595 ft. 625 fL Gray Hard Granite 777777777
(If well field,one laJIong is sufficient.) RGi4IAREeS _
35.921193 N -83.594787 W BIT SIZE-6.00"
6. Is(are)the well(s): . Permanent
22. Certification:7. Is this a repair to an existing well: NoY4& 12/22/2022
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Nell Contractor' Date
repair-under it 21 remark-s section or on the back ofthis form. Iy signing this forma I hereby certify that the well(s)was(were)constructed in accordimce
with 15AArCAC 02C.0100 or 15ANC4C 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 co",of this 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 form. You may use the back of this pageto provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 625 (fL)
For multiple wells tilt all depths ifdijferent(example-3@ 200'and 2 @ 100) SUMTTTAL INSTRUCTIONS l
24a.For AIR Wells: Submit this form virithin 30 days of completion of well
10.Static water level below top of casing: 220 (ft.)use"+" I '
If water level is above casing: constriction to the following: , I ,
Division of Water Qu..btyl Information Procession Drift,
11. Borehole diameter: 6 (n.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection Wells: - In addtion to sending the form to the address in 24a
12. Well construction method: Rotary air q i
(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 Qaalitp,'Undergrorm Injection Control Program,
1636\fail Service'Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 25 Method of test: Air 24c For*Vater Sunuly Inlectioul,R`e1Ls: 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 constriction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources -Division of Water Oua lity Revised Ian 2011