GW1-2023-01402_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 78 ft 80 iL
Well Contractor Name & fL
NCWC3491A 15.-OUTER CASING(for multi-'ehied wells)ORLI
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING o fL 25 ft- 6.125 in- SDR21 PVC plastic
Company Name fL fL in. ,
16.INNTsR CASING ORTURINP,geo afclos-a to'op)
2.Well Construction Permit#: W2022000626 515[75 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction pirtmits(ie Coun4,,State,Mariance,etc. ft. ft. i.
3.Well Use: ft. fL
E N
VwSi:311E, -'
FROlvf TO DIAMETER THICKNESS SLOT SIZE INfATERIAL
Residential ft & in
ft. fL in.
MU
IS.-GR M
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 fL Bentonite Pell -tts 150 Gravity
& ft.
FEB t) S 2023 fL - fL.1-
` NU
Prc-,;43=rvg i FROM TO MATERIAL EMPLACElvffiNT IvIETROD&AMOUNT
Dwom,oG ft- ft
4. Date Wells)Completed: 119/2023 Well 11M & ft
ft. ft.
5a. Well Location:
20,DRILLING LOG`(-.'Aiach additional sheets if necessary)
List all applicable well construction pertmits&County,State,Variance,etc, FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
FRANK LEDFORD 0 fL 4 & Brown Soft.Topsoil
Facility/Owner Name Facility ID(if applicable) 4fL 25 ft. Gray Hard'Granite SET CASING
10514 HWY 294 MURPHY 2M6 Lot 25& 78 ft. Gray Hard'Granite
physical Address,City,and Zip 78 iL 80 ft Gray LARGE FRACTURE 15 GPM
Cherokee 452400823183000 80 ft. 125 fL Gray Har&Granite
County parcel Identification No.(PIN) fL &
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: fL fL
(If well field,one lat/long is sufficient.) 21.'REMARKS1-,
35.125022 N -84.258386 W BIT SIZE-6.03"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No I 11�01 2 0 2 3
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back-of thisform. By signing thisforin.I hereby certify that the wells)was(were)constructed in accordance
with ISANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
8. Number of ivells 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 I 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: 125 (ft.)
For multiple wells list all depths ifelifferent(example-3@ 200'and 2 @ 100) SUAIMAL INSTRUCTIONS i.
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 00
lfwater level is above casing,use"+ construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 ("L) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In aildtion to sending the forni to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this for m 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): is Method of test: Air 24c.For Water Sunnly Injection Wells: In adiltion to sending the form to
the address(es)above,also submit I 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. I
Form GW-1 North Carolina Department of Environinent and Natural Resources -Division of Water I Quality Revised Jan 2013
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