GW1-2023-00988_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
I.Well ContContractor14.VATER ZONES
Contractor Information: - ZONES-____
TO DESCRIPTION
WILLIAM LAWSON
153 ft 154 fit
Well Contractor Name
189 fl. 191 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR•LINER(if applicable)
NC Well Contractor Certification Number FROM TO DLAR4ETER THICR-MESS 1%IATERL4L
CHEROKEE WELL DRILLING 0 ft- 60 R- 6.125 in. SDR 21 PVC plastic
Company Name ft. ft. in.
16.11\NER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000686 2021000381 FROM TO DL4METER TERC124ESS 1v4ATERIAL
List all applicable well construction permits(ie Coung;State,Variance,eta fL fL to
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DLAINIETE . TMCK-,MSS SLOT SIZE JIMATERIAL
Residential tl ft in.
fL fL in.
18.GROUT
�► i �r� E.1 EOM tI TO ft NIATERIAL EMPLACEIvIENI;METHOD 3:AMOUNT
* Rentonete 150 Gravity
JAN 18 2023 ft. ft.
ft. ft.
woowjai n P�rr.^�.c� UM 19.SAND/GRAVEL PACK(if applicable)
DVOW V OG FROM TO MATERIAL ENPLACE1,1ENT METHOD&AMOUNT
fl. ft.
fit. ft.
4. Date Well(s)Completed: 12/9/2022 Well ID#
ft. ft
5a. Well Location: 20.DRILLING-LOG(attach additional sheets if necessary) ---- -- -I
List all applicable well construction pertmits(ie County;State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
ROCCO BAUMSTARK 0 fL 38 fL Brown Medium Slate
Facility/OwnerName Facility ID(ifapplicable) 38 FL 60 fL 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 fL 154 ft. SMALL FRACTURE 5 GPM
Cherokee 458500945160000 154 fL 189 fit. Gray Hard Granite
County Parcel Identification No.(PIN) 189 ft. 191 ft. LARGE FRACTURE 15 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 191 ft. 245 fL Gray Hard Granite
(If well field,one latflong is sufficient.) 21.REMARI<S -
35.1.65403 N -84.056151 W BIT SIZE 6.09"
6. Is(are)the well(s): Permanent
22. Certification•
7. Is this a repair to an existing well: No 3
Ifthis is d repair,fill out known well construction information and explain the nature ofthe Signature o e ertitied Well Contractor Date
repair under#21 remar65 section or an the back ofthis form
By signing thisfornx I hereby cerhjy t/apt the well('s)was(were)cpnsnveted in accordance
with 15ANCAC 02C.0100 or 15AArCAC 02C.0200 Mel!Construction Standards and that a
S. Number of wells constructed: 1 copy ofthis record has been proiided 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 ofthis page to provide additional well site details or well
construction details. You may also allacii additional pages if necessary.
9.Total well depth below land surface: 245 00
For multiple wells list all depths if dideretrt(etannple-3@ 200'and 2 @ 100J SUMITT_4L INSTRUCTIONS
10.Static water level below top of casing: 50
24a.For A11 Wells: Submit thus fern within 30 days of completion of well
(ft.)
If water kn-el is above casing,use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in-) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection 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 ofthis fora 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 tilail Service Center,Raleigh,INC 27699-1636
13a. Yield(glint): 20 Method of test: Air 24c.For Water Supply Hrjection 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 county health department ofthe county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of'Hater Oualitv Revised Tan 2013