_Well Construction - GW1_20230310 (47)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON 270 ft. 271 ft.
Well Contractor Name 437 ft. 438 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 ft. 58 ft- 6.125 in- SDR 21 PVC plastic
Company Name ft ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000323 W2021200046 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pernnits(to County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN I
FROM TO DIAMETER I THICKNES SLOTS MATERIAL
Residential ft. ft. in.
ft. fL
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 20 ft.
MAR 4 tJ 2023 ft. ft
ft. ft.
19.SAND/GRAVEL PACK(if applicable) i
' ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
u .
ft. ft.
4. Date Well(s)Completed: 2/28/2023 Well ID# SERENITY RIDGE ft. ft.
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc)
CRUX CONSTRUCTION INC LOT 13 0 ft. 36 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 36ft. 58 ft. Gray Hand Granite Set Casing
AURORAS WAY LN MURPHY 28906 Lot 13 58 ft. 270 ft. Gray Hard Granite
Physical Address,City,and zip 270 ft 271 ft. Gray Hard Granite Small Fracture 1 GPM
Cherokee 456003427112000 271 ft. 437 ft. Gray Hard Granite
county Parcel Identification No.(PIN) 437 ft. 438 ft. Gray Hard Granite Small Fracture 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 438 ft. 605 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.020285 N -84.131203 W BIT SIZE 5.97"
6. Is(are)the well(s): Permanent
22. ee frcation: _
7. Is this a repair to an existing well: No � _ 3/1/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified WelioC&ntractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
S. Number of wells constructed: 1 copy 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 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: 605 (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: 100 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater level is above casing,use"+" 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 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): 2.5 Method of test: Air 24c.For Water Supply lniection 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 Oualitv Revised Jan 2013