GW1-2023-01008_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: Z4:�'VATER TON E
FROM TO DESCRIPTION
WILLIAM LAWSON 316 ft. 318 ft.
Well Contractor Name 337 ft. 338 tt.
NCWC3491A 15.OUTER CASLN\-(for.multi-caseti-weffs)OR,LINLR(ifappUcabie)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 fL 45 n- 6.125 in- SDR21 PVC plastic
Company Name ft. fi' In.
1&INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000617 2018000357 FROM TO DIAMETER THICI:TIESS IvL4TERIAL
List all applicable well construction pertmits(te County,State,Variance,etc. % ft. iIL
3.Well Use: ft. B' III'
17 SCREEN
FROM TO DIAIv1ETER THICKNESS SLOT SIZE 1v1ATERLXL
Residential ft. fL in.
ft. tit. in.
18.GROUT _ -
°"® "•°��+"'It
' 6�'� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
p�.Y ft. 20 ft
JAN 2 5 2023 ft. fl
ft. ft.
n -n-m j
11rt 19._S�N12/GRf� EI-PACK Cif apptli�sble)
{r1QGf rr1 p�
G4'3 Qi ur3C' FROIvl TO NMTERIAL EMPLACF&ENT METHOD&AMOUNT
fl. fl.
tit. fit.
4. Date Well(s)Completed: 1/14/2023 Well ID# TRIPLE CREEK LOTS N
ft. ft
5a. Well Location: 20.-DRILLLNG LOG(attach additional sheets if necessary), _
List all applicable well construction pertmits(ie Countl;State,f ariance,eta FRONI TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
GAHR PROPERTIES LLC 0 ft. 23 ft. Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 23 ft. 45 ft. Gray Hard Granite SET CASING
455 AWAHILI RIDGE RD MURPHY 28906 Lot 45& 316 fl. Gray Hard Granite
Physical Address,City,and Zip 316 ft. 318 ft. LARGE FRACTURE 14 GPM
Cherokee 452200587694000 318 ft. 337 M Gray Hard Granite
County Parcel Identification No.(PIN) 337 ft. 338 fit. SMALL FRACTURE 1 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 338 ft. 365 ft. Gray Hard Granite
(If well field,one lat/long is su8icient.) 21`REMARKS
36.088294 N -84.264691 W BIT SIZE-5.90"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 1/ 6/2023
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
repair under it 21 remarks section or on the back ofthisfo m. By signing this form,I hereby certify that the well(q)was(were)constructed in accordance
with 15ANCAC 02C.0100 or 1 SA NCAC 02C.0200 rVell Construction Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For mu Itiple 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 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: 365 (ft-)
For multiple wells list all depths ifdii different(example-3@ 200'and 2 @ 100) SUl1'1ITTAL INSTRUCTIONS
10.Static water level below top of casing: 120 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
1f water level is above casing use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11.-Borehole diameter: 6 Cm.) 1611 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Iniection 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): 15 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 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 Duality Revised Jan 2013