GW1-2023-01010_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD For hitemal Use ONLY:
This form can be used for single or mutiple wells
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1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 542 tit. 543 ft.
Well Contractor Name fL fL
NCWC3491 A 15:OUTER CASING'(for'mnit-cased yells)OR LINER Cifapplicabte)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 R- 55 R- 6.125 In- SDR21 PVC plastic
Company Name fL ft m
16.IN_NER CASING OR TUBLNG(geothermal closed loop)
2.Well Construction Permit#: W2022000551 W2022000550 FROM TO DIAMETER THICKK"NESS MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc, ft. ft. in.
I
3.Well Use: R' R' in.
17:SCREEN: `.;_.-'. _ -----
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft_ in.
ft. ft. in.
18.,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTr��.. �-i ' � ft. ft
20
ft. ft_
JAN 2 51023 f. ft.
. (,,a 19:S-ANDiGRA VEL-PACK(if applicable)
Jt1(G[FY'�GA*1Q)� ' FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 12/30/2022 Well ID# ft. ft.
ft. ft.
5a. Well Location: 20.DRILLLNG LOG(attach additional sheets if necessary), "
List all applicable well constriction pertntits(ie Counn;State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock-type,grain size,etc)
RICHARD PLEMMONS 0 ft_ 43 111. Yellow Medium Slate
Facility/OwnerN.ame Facility ID(ifapplicable) 43% 55 M Gray.Hard Granite
176 SADIES LN MURPHY 28906 Lot $5 ft 542 t Gray Hard Granite
Physical Address,City,and Zip 542 ft. 543: % SMALL FRACTURE 0.25 GPM
Cherokee. 458500118460000 543 ft_ 705 ft_ Gray Hard Granite
County Parcel Identification-No.(PIN) M fL
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: R• R'
(Ifvvell field,one lat/long is sufficient.) 21.REA'1ARKS =_
35.159133 N -84.080135 W BIT SIZE-6.12"
6. Is(are)the well(s): Permanent
22. Certification
•
7. Is this a repair to an e)dsting well: No 1/5/2023
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature ofCertifieflVell Contractor Date
repair under#21 remarks section or on the back-ofthisforne By signing thisformr I hereby certify that the well(s)was('were)constructed in accordance
with 15ANCAC 02C.0100 or 15A NCAC 02C_0200 Well Construction Standards and that a
S. Number of«'ells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water hells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one forme You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
9.Total well depth below laird surface: 705 (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: 520 (ft.) 24a.For All Wells: Submit this fomr within 30 days of completion of well
If water level is above casing,use"+" construction to the following:
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 air 24b.For Iniection«'ells: 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 form within 30 days of corpletion of well
construction to the following:
FOR WATER SUPPLY\YELLS ONLY: Division of AYater Quality,Uridergrotm Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0.25 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: 100 completion ofwell construction to the county health department ofthe county
where constructed.
Form GW-1 North Carolina Denartment of Environment and Natural Resources -Division of Water Oualitv Revised Ian 2013