GW1-2023-01896_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD'' For Internal Use ONLY.
This form can be used for single or mutiple wells
41'NXXTtkZ0,NM
1.NVeR Contractor Information:.
FROM TO DESCRIPTION---
WILLIAM LAWSON 195 ft. 196 ft.
Well Contractor Name 274 ft. 276 ft.
NCWC3491A OIJTER-ASERG(forimdIJ-- -,veel]_s)ORLITNrER-(1"0VycabIp),-
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 65 fL 6.125 hn- SDR-21 , PVC plastic
Company Name ft. fL HL
146-" '6�3*G Oil TUBI'N"q' �, clos .1oor ll\NEiR ed
2.XVell Construction Permit M W2022000433 2022000432 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance.eta % M in.
3.Well Use: & & in.
FROM TO DIAMETER T11lCM,1ESS SLOTSIM IAL
Residential M & hL
in.
IS.GROUT
FROM TO MATERLUti EMPLACF10ENT METHOD&AMOUNT
h6-4 ty 0 20 -ntonite Pell 1550 Gravity ft 9,
fL ft.
FEB 2 2 2023 ft. ft.
dRkNtL-P.-:VCK-,' "pli b I inj If�11-t----- - -c�,-'-)— , --- ----':7.'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
4. Date Well(s)Completed: 11/30/2022 Well IM HOLLYPOINT 6
ft. fL
5a. Well Location:
id.-DRILLING LOG(attach additional sheets lfy-i'ec'essary)
List all applicable well construction pertmi is(ie Count};State,Variance,eta FROM TO DESCRIPTION(color,hardness,soilhock type,grain size,etc)
MICHELE HILTON LOT 44 Oft. 40 ft. Brown Medium SlEite'
Facility/Owner Name Facility ID(ifapplicable) 40 fL 65 ft. Gray Hard I!G ranite SET CASING
460 HOLLY POINT DR MURPHY 28906 Lot 44 HOLLY POINT 65 ft. 195 fL Gray Hard.Granite
Physical Address,City and Zip 195 ft. 196 11L SMALL)FRACTLIRE I GPM
Cherokee 446900197742000 196 ft. 274 ft. Gray Hard Granite
County Parcel'Identification No.(PIN) 274& 276 ft. LARGE FRACTURE 19 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 276 fL 305 ft- Gray. Hard:Granite
(If well field,one lat/long is sufficient)
35.013887 N -84.1401 W BIT SIZE-6.10"
11
6. Is(are)the well(s): Permanent
22.
A 1
7. Is this a repair to an existing well: No P- - 12M12022
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contract— f--—Die
repair under#21 remarks section or on the back of this form WV�,certi that Me well(s)was were constructed in accordance
Ry signing 1hisjbr!?z,I he) fy tl
with 15A AICAC 02C.0100 or 15A AICAC 02C.0200 rVell 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:
subunit oneforM. You may use the back ofthis page4o provide additional well site details or well
construction details- You may also attach additional pages ifnece&&-uy.
9.Total well depth below land surface: 305
For multiple wells List all depths ifdifferent(example-3@ 200'and 2 @ 100'.) SUMITTAL INiSTRUCTIOINS
I.
24a.For All Wells: Submit this forrilwithin 30 days of completion of well
10.Static water level below top of casing: 80 construction to the following.
If water level is above casing,use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (i-) 1617 Nfail Service Center,Raleigh,INC 27699-1617
1 1
12.'Well,construction method: Rotary air 24b.For IniectionWells: In adiltion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy ofthis f ' �wfthin 30 days ofcompletion of wall
,U SUPPLY WELLS ONLY: construction to the following:
I OF
FOR WATER " Division of*Vater Quality Undergroun Injection Control Program,
1636 MAU Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Supply Injection Wells: In adiltion to sending the form to
the address(es)above,also submit dnd copy ofthis form within 30 days of
13h. Disinfection type: HTH Amount: 100 completion of wellconstruction to tiie county health department ofthe county
where constructed- I I
Form GVV-1 North Carolina Department ofEnvirannient and Natural Resources -Division or water Oualitv Revised Ian 2013