_Well Construction - GW1_20230327 (14)

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 254 ft. 255 ft.
Well Contractor Name 330 ft. 331 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. 226 ft 6.125 in. .188 Steel-black
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000081 2022000080 FROM TO DIAMETER TFHCKNESl MATERIAL
List all applicable well construction pertmits(le County,Stale, Variance,etc ft ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER TMCKNES SLOT S MATERIAL
Residential ft. ft. in.
_ ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
MAR 2 7 2023 0 ft. ft. ntan
ft. ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 3/9/2023 Well ID# 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,soil/rock type,grain size,etc)
CHRISTINA GUTHRIE 0 ft. 190 ft. Tan Medium Slate
Facility/Owner Name Facility ID(if applicable) 190 ft. 226 ft. Gray Hard Slate Set Casing
1044 BLAIRSVILLE HWY MURPHY 28906 Lot 226 ft. 254 ft. Gray Hard Slate
Physical Address,City,and zip 254 ft. 255 ft. Gray Hard Slate Small Fracture 2 GPM
Cherokee 457019516411000 255 ft. 330 % Gray Hard Granite
County Parcel Identification No.(PIN) 330 ft. 331 ft. Gray Hard Granite Small Fracture 7 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 331 ft. 1405 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.020231 N -84.092615 W BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certifica ions
7. Is this a repair to an existing well: No 1A A ",7n1 ' / e 3/10/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well CoWF96ior Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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: 405 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 120 (ft.) construction to the following:
If water 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 Injection 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): 9 Method of test: Air 24c.For Water Supply-Innection 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-I North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013